Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Microbiological profile of patients treated for postoperative peritonitis: temporal trends 1999-2019

BACKGROUND

Temporal changes in the microbiological resistance profile have been reported in several life-threatening infections. However, no data have ever assessed this issue in postoperative peritonitis (POP). Our purpose was to assess the rate of multidrug-resistant organisms (MDROs) in POP over a two-decade period and to analyse their influence on the adequacy of empirical antibiotic therapy (EAT).

METHODS

This retrospective monocentric analysis (1999-2019) addressed the changes over time in microbiologic data, including the emergence of MDROs and the adequacy of EAT for all intensive care unit adult patients treated for POP. The in vitro activities of 10 antibiotics were assessed to determine the most adequate EAT in the largest number of cases among 17 antibiotic regimens in patients with/without MDRO isolates. Our primary endpoint was to determine the frequency of MDRO and their temporal changes. Our second endpoint assessed the impact of MDROs on the adequacy of EAT per patient and their temporal changes based on susceptibility testing. In this analysis, the subgroup of patients with MDRO was compared with the subgroup of patients free of MDRO.

RESULTS

A total of 1,318 microorganisms were cultured from 422 patients, including 188 (45%) patients harbouring MDROs. The growing proportions of MDR Enterobacterales were observed over time (p = 0.016), including ESBL-producing strains (p = 0.0013), mainly related to Klebsiella spp (p < 0.001). Adequacy of EAT was achieved in 305 (73%) patients. Decreased adequacy rates were observed when MDROs were cultured [p = 0.0001 vs. MDRO-free patients]. Over the study period, decreased adequacy rates were reported for patients receiving piperacillin/tazobactam in monotherapy or combined with vancomycin and imipenem/cilastatin combined with vancomycin (p < 0.01 in the three cases). In patients with MDROs, the combination of imipenem/cilastatin + vancomycin + amikacin or ciprofloxacin reached the highest adequacy rates (95% and 91%, respectively) and remained unchanged over time.

CONCLUSIONS

We observed high proportions of MDRO in patients treated for POP associated with increasing proportions of MDR Enterobacterales over time. High adequacy rates were only achieved in antibiotic combinations involving carbapenems and vancomycin, while piperacillin/tazobactam is no longer a drug of choice for EAT in POP in infections involving MDRO.

Mid-Regional Pro-Adrenomedullin Can Predict Organ Failure and Prognosis in Sepsis?

Sepsis causes immune dysregulation and endotheliitis, with an increase in mid-regional pro-adrenomedullin (MR-proADM). The aim of the study is to determine an MR-proADM value that, in addition to clinical diagnosis, can identify patients with localized infection or those with sepsis/septic shock, with specific organ damage or with the need for intensive care unit (ICU) transfer and prognosis. The secondary aim is to correlate the MR-proADM value with the length of stay (LOS). In total, 301 subjects with sepsis (124/301 with septic shock) and 126 with localized infection were retrospectively included. In sepsis, MR-proADM ≥ 3.39 ng/mL identified acute kidney injury (AKI); ≥2.99 ng/mL acute respiratory distress syndrome (ARDS); ≥2.28 ng/mL acute heart failure (AHF); ≥2.55 ng/mL Glascow Coma Scale (GCS) < 15; ≥3.38 multi-organ involvement; ≥3.33 need for ICU transfer; ≥2.0 Sequential Organ Failure Assessment (SOFA) score ≥ 2; and ≥3.15 ng/mL non-survivors. The multivariate analysis showed that MR-proADM ≥ 2 ng/mL correlates with AKI, anemia and SOFA score ≥ 2, and MR-proADM ≥ 3 ng/mL correlates with AKI, GCS < 15 and SOFA score ≥ 2. A correlation between mortality and AKI, GCS < 15, ICU transfer and cathecolamine administration was found. In localized infection, MR-proADM at admission ≥ 1.44 ng/mL identified patients with AKI; ≥1.0 ng/mL with AHF; and ≥1.44 ng/mL with anemia and SOFA score ≥ 2. In the multivariate analysis, MR-proADM ≥ 1.44 ng/mL correlated with AKI, anemia, SOFA score ≥ 2 and AHF. MR-proADM is a marker of oxidative stress due to an infection, reflecting severity proportionally to organ damage.

Optimizing transitions of care antimicrobial prescribing at a community teaching hospital

Objective

Antibiotic prescribing at hospital discharge is an important focus for antimicrobial stewardship efforts. This study set out to determine the impact of a pharmacist-led intervention at hospital discharge on appropriate antimicrobial prescribing.

Design

This was a pre-/post-study evaluating the impact of a pharmacist-led review on antibiotic prescribing at hospital discharge. Pharmacists evaluated antibiotic prescriptions at discharge for appropriate duration, spectrum of activity, frequency, and strength of dose. Each of these criteria needed to be met for an antibiotic regimen to be considered appropriate.

Setting

Moses Cone Hospital is a 535-bed community teaching hospital in Greensboro, North Carolina.

Patients or Participants

Patients ≥18 years of age discharged from the hospital with an antibiotic prescription were included. Exclusion criteria included patients discharged against medical advice, discharged to a skilled nursing facility, or prescribed indefinite prophylactic antimicrobial therapy.

Interventions

A review of patients discharged with antibiotics in 2020 was performed. Patients discharged with antibiotic prescriptions from January 2021 to April 2022 were evaluated prior to discharge by pharmacists. The pharmacist made recommendations to providers based on their evaluations.

Results

162 retrospective patients were screened, and 136 patients were screened at discharge from the hospital in the prospective cohort. 76/162 (47%) retrospective patients received appropriate antibiotic therapy at discharge, while 92/136 (68%) of prospective patients received appropriate discharge therapy (p = 0.001).

Conclusions

In this study examining the efficacy of stewardship pharmacist intervention at hospital discharge, pharmacist review and recommendations were associated with an increased rate of appropriate antimicrobial prescribing.

Ethics statement

This study was conducted under the approval of the Institutional Review Board of the Moses H. Cone Health System. The approval protocol number was 1483117-1 and took effect on September 2nd, 2019. As the research was either retrospective in nature or part of the standard of care recommendations, the project was granted expedited review.

Tolerability of pulsed high-dose L-AmB as pre-emptive therapy in patients at high risk for intra-abdominal candidiasis: A phase 2 study (LAMBDA study)

BACKGROUND

Intra-abdominal candidiasis (IAC) has a high mortality rate. However, the correct management of a critically ill patient with suspected IAC remains unclear. The aim of this study was to evaluate the safety of pulsed high-dose liposomal amphotericin B (L-AmB) in patients with suspected IAC managed with a beta-D-glucan (BDG)-guided strategy.

METHODS

This phase 2 prospective study enrolled adult patients with intra-abdominal sepsis following surgery. Patients received a single dose of L-AmB 5 mg/kg on day 1. On day 3, L-AmB was discontinued in patients with a negative basal BDG result, and continued (3 mg/kg/daily) in patients with a positive basal BDG result or microbiologically confirmed IAC. The primary endpoint was the occurrence of adverse events, defined using the Common Toxicity Criteria classification.

RESULTS

In total, 40 patients were enrolled from January 2019 to August 2022. Fifteen (37.5%) patients were male, and the median age was 65 [interquartile range (IQR) 49-76] years. Thirty-one (77.5%) patients underwent urgent surgery, and the principal indication was secondary/tertiary peritonitis (n=22, 55%); half of the patients had undergone a previous surgical operation within the preceding 30 days. Five (12.5%) patients met the criteria for septic shock at enrolment. The median APACHE II score on admission to the intensive care unit was 12 (IQR 10-15). IAC was excluded in 33 (85%) patients, but IAC was probable and proven in five (12.5%) and two (5%) patients, respectively. The single dose of L-AmB 5 mg/kg was well tolerated in all patients, and no early or late severe adverse events related to the drug were reported. L-AmB was discontinued in 65% of patients following a negative basal BDG result. The all-cause 30-day mortality rate was 15%, and no deaths were related to L-AmB administration or uncontrolled IAC. The mortality rates for patients with and without proven IAC were 0% and 15.8%, respectively (P=0.99).

CONCLUSIONS

The rate of proven IAC among critically ill high-risk patients was low (5%). A single dose of L-AmB 5 mg/kg, with prompt withdrawal in the case of a basal negative BDG result, seems to be a safe and effective approach in this population.

Cefepime Versus Piperacillin-Tazobactam for the Treatment of Intra-Abdominal Infections Secondary to Potential AmpC Beta-Lactamase-Producing Organisms

Background: Recent studies have established cefepime as an effective treatment option for AmpC beta-lactamase (AmpC) Enterobacterales; however, the efficacy of beta-lactam/beta-lactamase inhibitors is unclear. Objective: The objective of this study was to determine if piperacillintazobactamis an appropriate alternative to cefepime for the treatment of intra-abdominal infections (IAIs) secondary to AmpC-producing organisms. Methods: This multicenter, retrospective cohort study was conducted in hospitalized adults with an IAI caused by an AmpC-producing organism and received either cefepime or piperacillin-tazobactam for definitive treatment after a source control procedure. The primary outcome was a composite of surgical site infections, recurrent IAIs, or in-hospital mortality. Secondary outcomes included the individual components of the composite outcome, hospital length of stay (LOS), microbiologic failure, study antibiotic duration, time to clinical resolution, and incidence of Clostridioides difficile infection (CDI). Results: This study included 119 patients. There was no difference in the primary outcome between the cefepime and piperacillin-tazobactam groups (35% vs 27%, P = 0.14). Microbiological failure was the only secondary outcome with an observed difference between groups (17% vs 0%, P = 0.01): hospital LOS (15 vs 13 days, P = 0.09), days of therapy (7 vs 7 days, P = 0.87), time to clinical resolution (7 vs 4 days, P = 0.30), and CDI (1% vs 2%, P = 0.58) were all similar.

Antibiotic use in Canadian neonatal intensive care units: a national survey for developing antimicrobial stewardship targets

A survey was conducted among Canadian tertiary neonatal intensive care units. Of the 27 sites who responded, 9 did not have any form of antimicrobial stewardship, and 11 used vancomycin for empirical coverage in late-onset-sepsis evaluations. We detected significant variations in the diagnostic criteria for urinary tract infection and ventilator-associated pneumonia.

Neurological Manifestations of Infectious Diseases: Insights From Recent Cases

This narrative review examines the complex connection between infectious diseases and their neurological effects. It provides a detailed analysis of recent instances and insights derived from various pathogens. As we explore the realm of infectious agents, including viruses, bacteria, parasites, and fungi, a thorough and diverse analysis reveals the intricacies of neurological problems. The review begins by examining viral infections, specifically focusing on how viruses invade the neurological system and its subsequent effects. Significant instances from recent widespread disease outbreaks function as instructive benchmarks, highlighting the progressing comprehension of these ever-changing interconnections. The article examines the complex pathophysiology of neurological problems caused by bacterial infections. It presents current cases that illustrate the various ways these complications might manifest and the difficulties faced in their therapeutic management. Parasitic and fungal infections, which are typically overlooked, are being carefully examined to emphasize their distinct role in causing neurological complications. The mentioned cases highlight the importance of being thoroughly aware of these less-explored areas ranging from protozoan parasites to opportunistic fungal infections. In addition to the immediate effects caused by infectious agents, the review investigates autoimmune responses activated by infections. It provides a detailed examination of specific instances that shed light on the complex relationship between viral triggers and future neurological problems. This text elaborates on the intricacy of autoimmune-related neurological issues, highlighting the necessity for a comprehensive approach to diagnosing and treating them. The narrative next redirects its attention to the diagnostic difficulties that arise when interpreting the neurological symptoms of viral disorders. This article provides a thorough examination of existing diagnostic tools, along with an investigation into new technologies that have the potential to improve our capacity to identify and comprehend complex presentations. This debate connects to the following examination of treatment methods, where current cases that showcase successful interventions are carefully examined to extract valuable insights into good clinical management. The discussion focuses on the public health implications of preventive efforts against infectious infections, including their neurological consequences. The story emphasizes the link between infectious diseases and overall societal health, advocating for a proactive strategy to reduce the impact of neurological complications. The abstract concludes by providing a prospective viewpoint, highlighting areas of research that still need to be addressed, and suggesting potential future avenues. This narrative review seeks to provide a comprehensive resource for physicians, researchers, and public health professionals dealing with the complex field of neurological manifestations in infectious diseases. It combines recent examples, synthesizes current information, and offers a holistic perspective.

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.

Resuscitation and Preparation of the Emergency General Surgery Patient

Traditionally, the workflow surrounding a general surgery patient allows for a period of evaluation and optimization of underlying medical issues to allow for risk modification; however, in the emergency, this optimization period is largely condensed because of its time-dependent nature. Because the lack of optimization can lead to complications, the ability to rapidly resuscitate the patient, proceed to procedural intervention to control the situation, and manage common medical comorbidities is paramount. This article provides an overview on these subjects.

Comparison of Cefazolin and Ceftriaxone as Antimicrobial Prophylaxis in Pancreatoduodenectomy with Preoperative Drainage: Incidence of Surgical Site Infection and Susceptibility of Bacteria in Bile

BACKGROUND

The optimal perioperative antimicrobial agent for preventing surgical site infection (SSI) in pancreatoduodenectomy (PD) with preoperative biliary drainage (PBD) remains unclear.

METHODS

We retrospectively reviewed 288 patients who underwent PD after PBD between 2010 and 2020 at our institution. Patients were classified into two groups according to the perioperative antimicrobial agent used (cefazoline [CEZ] group [n = 108] and ceftriaxone [CTRX] group [n = 180]). The incidence of SSI, type of bacteria in intraoperative bile culture (IBC), and antimicrobial susceptibility to prophylactic antimicrobial agents were analyzed.

RESULTS

The incidence of incisional SSI was significantly lower in the CTRX group than in the CEZ group (18% vs. 31%, P = 0.021), whereas the incidence of organ/space SSI in the two groups did not differ to a statistically significant extent (35% vs. 44%, P = 0.133). Gram-negative rod (GNR) bacteria in the IBC showed better antimicrobial susceptibility in the CTRX group than in the CEZ group. In multivariate analysis, antimicrobial resistance due to GNR was a significant risk factor for incisional SSI (odds ratio, 3.50; P < 0.001).

CONCLUSIONS

CTRX had better antimicrobial coverage than CEZ for GNR cultured from intraoperative bile samples. In addition, CTRX provides better antimicrobial prophylaxis than CEZ against superficial SSI in patients with PD after PBD.

TRIAL REGISTRATION NUMBER

This study was not a clinical trial and had no registration numbers.

Identification of Risk Factors for Intra-Abdominal Candidiasis

Background: Intra-abdominal candidiasis (IAC) is associated with substantial morbidity and mortality in hospitalized patients. Identifying high-risk populations may facilitate early and selective directed therapy in appropriate patients and avoid unwarranted treatment and any associated adverse effects in those who are low risk. Patients and Methods: This retrospective, case-control study included patients >18 years of age admitted from July 1, 2010 to July 1, 2021 who had a microbiologically confirmed intra-abdominal infection (gastrointestinal culture positive for either a Candida spp. [cases] or bacterial isolate [controls] collected intra-operatively or from a drain placed within 24 hours). Patients receiving peritoneal dialysis treatment or with a peritoneal dialysis catheter in place or treated at an outside hospital were excluded. Multivariable regression was utilized to identify independent risk factors for the development of IAC. Results: Five hundred twenty-three patients were screened, and 250 met inclusion criteria (125 per cohort). Multivariable analysis identified exposure to corticosteroids (odds ratio [OR], 5.79; 95% confidence interval [CI], 2.52-13.32; p < 0.0001), upper gastrointestinal tract surgery (OR, 3.51; 95% CI, 1.25-9.87; p = 0.017), and mechanical ventilation (OR, 3.09; 95% CI 1.5-6.37; p = 0.002) were independently associated with IAC. The area under the receiver operating characteristic (AUROC) and goodness of fit were 0.7813 and p = 0.5024, respectively. Conclusions: Exposure to corticosteroids, upper gastrointestinal tract surgery, and mechanical ventilation are independent risk factors for the development of microbiologically confirmed IAC suggesting these factors may help identify high-risk individuals requiring antifungal therapy.

Network meta-analysis of antibiotic resistance patterns in gram-negative bacterial infections: a comparative study of carbapenems, fluoroquinolones, and aminoglycosides

Introduction

Antimicrobial resistance poses a grave global threat, particularly with the emergence of multidrug-resistant gram-negative bacterial infections, which severely limit treatment options. The increasing global threat of antimicrobial resistance demands rigorous investigation, particularly concerning multidrug-resistant gram-negative bacterial infections that present limited therapeutic options. This study employed a network meta-analysis, a powerful tool for comparative effectiveness assessment of diverse antibiotics. The primary aim of this study was to comprehensively evaluate and compare resistance patterns among widely used antibiotic classes, namely carbapenems, fluoroquinolones, and aminoglycosides, for combating gram-negative pathogens.

Methods

We searched PubMed, Web of Sciences, Scopus, Scholarly, Medline, Embase, and Cochrane databases up to August 27, 2023. Studies showing antibiotic resistance in clinical isolates of Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii exposed to carbapenems, fluoroquinolones, and aminoglycosides were included. This study determined treatment-specific resistance percentages and ranked these treatments based on resistance using a random-effects network meta-analysis technique. To investigate the impact of the study and pathogen features, subgroup and meta-regression analyses were performed. Risk ratios and 95% confidence intervals (CIs) were calculated using a network meta-analysis (NMA) incorporating both direct and indirect evidence. Clinical improvement, cure, microbiological eradication, and death from any cause were the primary outcomes. Nephrotoxicity was a secondary result.

Results

The analysis included 202 publications and 365,782 gram-negative isolates. The NMA included data from 20 studies and 4,835 patients. Carbapenems had the lowest resistance rates throughout the pathogen spectrum, with resistance percentages of 17.1, 22.4, and 33.5% for Enterobacteriaceae, P. aeruginosa, and A. baumannii, respectively. For the same infections, aminoglycosides showed resistance rates of 28.2, 39.1, and 50.2%, respectively. Fluoroquinolones had the highest resistance rates at 43.1, 57.3, and 65.7%, respectively. Unexpectedly, resistance to all three antibiotic classes has increased over time, with multidrug resistance being the most prevalent.

Conclusion

This extensive network meta-analysis provides an overview of the patterns of resistance throughout the world and how they are changing. The most effective choice is still carbapenems, but the increasing resistance highlights the critical need for multimodal therapies to protect antibiotic effectiveness against these powerful gram-negative infections.

Compass for antibiotic stewardship: using a digital tool to improve guideline adherence and drive clinician behaviour for appendicitis treatment in the emergency department

BACKGROUND

Antibiotic stewardship in the ED is important given the increasing prevalence of multidrug resistance associated with poorer patient outcomes. The use of broad-spectrum antibiotics in the ED for infections like appendicitis is common. At baseline, 75% of appendicitis cases at our institution received broad-spectrum ertapenem rather than the recommended narrower-spectrum ceftriaxone/metronidazole combination. We aimed to improve antibiotic stewardship by identifying barriers to guideline adherence and redesigning our appendicitis antibiotic guideline.

METHODS

Using the 'Fit between Individuals, Task and Technology (FITT)' framework, we identified barriers that preventclinicians from adhering to guidelines. We reformatted a clinical guideline and disseminated it using our ED's clinical decision support system (CDSS), E*Drive. Next, we examined E*Drive's user data and clinician surveys to assess utilisation and satisfaction. Finally, we conducted a retrospective chart review to measure clinician behaviour change in antibiotic prescription for appendicitis treatment.

RESULTS

Data demonstrated an upward trend in the number of monthly users of E*Drive from 1 April 2021 to 30 April 2022, with an average increase of 46 users per month. Our clinician survey results demonstrated that >95% of users strongly agree/agree that E*Drive improves access to clinical information, makes their job more efficient and that E*Drive is easy to access and navigate, with a Net Promoter Score increase from 26.0 to 78.3. 69.4% of patients treated for appendicitis in the post-intervention group received antibiotics concordant with our institutional guideline compared with 20.0% in the pre-intervention group (OR=9.07, 95% CI (3.84 to 21.41)).

CONCLUSION

Antibiotic stewardship can be improved by ensuring clinicians have access to convenient and up-to-date guidelines through clinical decision support systems. The FITT model can help guide projects by identifying individual, task and technology barriers. Sustained adherence to clinical guidelines through simplification of guideline content is a potentially powerful tool to influence clinician behaviour in the ED.

Effect of Pharmacoprophylaxis on Postoperative Outcomes in Adult Elective Colorectal Surgery: A Multi-Center Retrospective Cohort Study within an Enhanced Recovery after Surgery Framework

BACKGROUND

The application of enhanced recovery after surgery principles decreases postoperative complications (POCs), length of stay (LOS), and readmissions. Pharmacoprophylaxis decreases morbidity, but the effect of specific regimens on clinical outcomes is unclear.

METHODS AND MATERIALS

Records of 476 randomly selected adult patients who underwent elective colorectal surgeries (ECRS) at 10 US hospitals were abstracted. Primary outcomes were surgical site infection (SSI), venous thromboembolism (VTE), postoperative nausea and vomiting (PONV), pain, and ileus rates. Secondary outcomes included LOS and 7- and 30-day readmission rates.

RESULTS

POC rates were SSI (3.4%), VTE (1.5%), PONV (47.9%), pain (58.1%), and ileus (16.1%). Cefazolin 2 g/metronidazole 500 mg and ertapenem 1 g were associated with the shortest LOS; cefotetan 2 g and cefoxitin 2 g with the longest LOS. No SSI occurred with ertapenem and cefotetan. More Caucasians than Blacks received oral antibiotics before intravenous antibiotics without impact. Enoxaparin 40 mg subcutaneously daily was the most common inpatient and discharge VTE prophylaxis. All in-hospital VTEs occurred with unfractionated heparin. Most received rescue rather than around-the-clock antiemetics. Scopolamine patches, spinal opioids, and IV lidocaine continuous infusion were associated with lower PONV. Transversus abdominis plane block with long-acting local anesthetics, celecoxib, non-anesthetic ketamine bolus, ketorolac IV, lidocaine IV, and pregabalin were associated with lower in-hospital pain severity rates. Gabapentinoids and alvimopan were associated with lower ileus rates. Acetaminophen, alvimopan, famotidine, and lidocaine patches were associated with shorter LOS.

CONCLUSIONS

Significant differences in pharmacotherapy regimens that may improve primary and secondary outcomes in ECRS were identified. In adult ECRS, cefotetan or ertapenem may be better regimens for preventing in-hospital SSI, while ertapenem or C/M may lead to shorter LOS. The value of OA to prevent SSI was not demonstrated. Inpatient enoxaparin, compared to UFH, may reduce VTE rates with a similar LOS. A minority of patients had a documented PONV risk assessment, and a majority used as-needed rather than around-the-clock strategies. Preoperative scopolamine patches continued postoperatively may lower PONV and PDNV severity and shorter LOS. Alvimopan may reduce ileus and shorten LOS. Anesthesia that includes TAP block, ketorolac IV, and pregabalin use may lead to reduced pain rates. Acetaminophen, alvimopan, famotidine, and lidocaine patches may shorten LOS. Given the challenges of pain management and the incidence of PONV/PDNV found in this study, additional studies should be conducted to determine optimal opioid-free anesthesia and the benefit of newer antiemetics on patient outcomes. Moreover, future research should identify latent pharmacotherapy variables that impact patient outcomes, correlate pertinent laboratory results, and examine the impact of order or care sets used for ECRS at study hospitals.

Comparative Analysis of Antibiotic Resistance in Acute Cholangitis Patients with Stent Placement and Sphincterotomy Interventions

In response to rising concerns over multidrug resistance patterns in acute cholangitis patients, this retrospective study was conducted at the Emergency County Hospital Timisoara, Romania, encompassing patients treated between August 2020 and August 2023. The study aimed to investigate the influence of prior interventions, specifically sphincterotomy (with or without stent placement), on the current clinical and microbiological profiles of acute cholangitis patients. By differentiating between patients with a history of sphincterotomy and the endoscopic retrograde cholangiopancreatography (ERCP)-naïve, we assessed the resistance of bacterial strains to antibiotics by the Tokyo Guidelines 2018, using bile cultures from 488 patients. The study identified various multidrug-resistant organisms, with a total multidrug resistance incidence of 19.9%. Significant variations were observed in the distribution of specific microorganisms and resistance patterns across different intervention groups. Patients with previous interventions, particularly those with both sphincterotomy and stent, exhibited elevated white blood cells (WBC) and C-reactive protein (CRP) levels in comparison to their ERCP-naïve counterparts. This group also presented a striking prevalence of two bacteria in their bile cultures at 50.0%, compared to 16.1% in ERCP-naïve individuals. Regarding multidrug resistance, the prior sphincterotomy with stent placement had a prevalence of 50.0%. The presence of ESBL bacteria was also significantly higher in the same group at 28.7%, contrasting with the 8.9% in ERCP-naïve patients. Additionally, the same group had a higher burden of Klebsiella spp. infections, at 37.2%, and Enterococcus spp. at 43.6%. On the antibiotic resistance front, disparities persisted. Piperacillin/Tazobactam resistance was notably more rampant in patients with a previous sphincterotomy and stent, registering at 25.5% against 11.1% in the ERCP-naïve group. This study underscores a substantial discrepancy in multidrug resistance patterns and antibiotic resistance among acute cholangitis patients with previous manipulation of the bile ducts, without expressing significant differences by the type of stent used.

Reducing the duration of antibiotic therapy in surgical patients through a specific nationwide antimicrobial stewardship program. A prospective, interventional cohort study

BACKGROUND

Guidelines recommend 5-7 days of antibiotic treatment in patients with surgical infection and adequate source control. This nationwide stewardship intervention aimed to reduce the duration of treatments in surgical patients to <7 days.

METHODS

Prospective cohort study evaluating surgical patients receiving antibiotics ≥7 days in 32 hospitals. Indication for treatment, quality of source control, type of recommendations issued, and adherence to the recommendations were analysed. Temporal trends in the percentages of patients with treatment >7 days were evaluated using a linear regression model and Pearson's correlation coefficients.

RESULTS

A total of 32 499 patients were included. Of these, 13.7% had treatments ≥7 days. In all, 3912 stewardship interventions were performed, primarily in general surgery (90.7%) and urology (8.1%). The main types of infection were intra-abdominal (73.4%), skin/soft tissues (9.8%) and urinary (9.2%). The septic focus was considered controlled in 59.9% of cases. Out of 5458 antibiotic prescriptions, the most frequently analysed drugs were piperacillin/tazobactam (21.7%), metronidazole (11.2%), amoxicillin/clavulanate (10.3%), meropenem (10.7%), ceftriaxone (9.3%) and ciprofloxacin (6.7%). The main recommendations issued were: treatment discontinuation (35.0%), maintenance (40.0%) or de-escalation (15.5%), and the overall adherence rate was 91.5%. With adequate source control, the most frequent recommendation was to terminate treatment (51.2%). Throughout the study period, a significant decrease in the percentage of prolonged treatments was observed (Pc=-0.69;P < 0.001).

CONCLUSIONS

This stewardship programme reduced the duration of treatments in surgical departments. Preference was given to general surgery services, intra-abdominal infection, and beta-lactam antibiotics, including carbapenems. Adherence to the issued recommendations was high.

AntibiogramDSM: a combined local antibiogram and educational intervention

Objective

To describe the development of a combined local antibiogram and assess its utility in an educational intervention.

Design

Retrospective analysis of a combined, multi-healthcare system antibiogram with an educational intervention and pre-post analysis.

Setting

Creation of the combined antibiogram included all health systems in Des Moines, Iowa. The educational intervention was delivered live via webinar and remained available on demand for one year.

Participants

The combined antibiogram participants included four health systems representing eight hospitals. The educational intervention included 45 healthcare providers (15 live, 30 on demand) who elected to participate.

Methods

Yearly antibiograms were collected from four health systems for 2017 and 2018 and from three health systems for 2019 and 2020. Each was aggregated into a single antibiogram, posted online, and analyzed retrospectively. In 2021, an educational intervention took place, which included pre-educational assessments, a one-hour presentation on local resistance rates and impact on common infections, and post-education assessments. The educational session was available online for one year. Correct responses before and after education were compared using NcNemar's test.

Results

Over 4 yr, 123,168 isolates were included in the antibiogram, representing 57 species and 46 tested antibiotics. Before education, prediction of local resistance rates for E. coli and S. pneumoniae was poor. After the education session, there was improvement in the proportion of correct responses to case-based questions: pneumonia (31.8% vs 58.8%, P = 0.022), UTI (47.7% vs 85.3%, P < 0.001), sinusitis (75% vs 91.2%, P = 0.109), and diverticulitis (43.2% vs 88.2%, P = 0.002).

Conclusions

A combined local antibiogram was useful in supporting an outpatient education program.

Antimicrobial Stewardship in Neonates with Necrotizing Enterocolitis: A Quality Improvement Initiative

BACKGROUND

Antibiotic overutilization in the neonatal intensive care unit (NICU) has many adverse effects, and necrotizing enterocolitis (NEC) is one of the most common indications for antibiotics in premature infants. Evidence for a preferred antibiotic regimen for NEC is lacking. This project aims to reduce piperacillin-tazobactam use and overall antibiotic duration in neonates with NEC through the implementation of an antibiotic stewardship pathway based on the modified Bell stage classification system.

METHODS

A multidisciplinary team consisting of neonatology, pharmacy, infectious disease, and surgery developed an antibiotic protocol for the management of NEC based on Bell stage. Recommendations included 48 h of ampicillin/gentamicin (AG) for stage I, 5-10 days of AG for stage II, the addition of metronidazole for stage IIIA, and 7-14 days of piperacillin-tazobactam (PT) for stage IIIB. We evaluated overall antibiotic and PT exposure, progression to surgical NEC, NEC recurrence, antibiotic resistance, bacteremia/fungemia, and mortality 1 year pre- and post-protocol implementation.

RESULTS

27 patients pre-intervention and 44 post-intervention were analyzed. Antibiotic exposure was reduced from a median 119.19 to 80.65 days of therapy (DOT) per 1000 patient days (p = 0.11). PT exposure decreased after protocol implementation (median 68.78 vs. 7.97 DOT per 1000 patient days, p = 0.002). There were no significant differences in morbidity or mortality outcomes.

CONCLUSIONS

Antibiotic stewardship strategies can be implemented in the NICU without compromising outcomes in patients with NEC. Bell stage stratification appears to be an effective method for antibiotic selection. Further studies are needed in a larger population to optimize regimens and ensure safety.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Acute pancreatitis in children: risk factors, management, and outcomes

PURPOSE OF REVIEW

Pediatric acute pancreatitis is an infrequent but potentially serious condition in children. Most have mild cases with spontaneous resolution, but up to one-third of patients can have moderate or severe disease or progress to recurrent or chronic pancreatitis.

RECENT FINDINGS

Significant advances have been made in the field of pediatric pancreatology with a recognition that pediatric acute pancreatitis can vary significantly from adult disease with different risk factors and outcomes. There is better understanding of appropriate management for pediatric pancreatitis as well as growing literature in complications of pancreatitis.

SUMMARY

The most common risk factors for pediatric acute pancreatitis include biliary disease, drug/toxin and idiopathic. Management involves adequate fluid resuscitation, early enteral nutrition and appropriate pain control. Systemic and local complications, including SIRS, necrosis and fluid collections, can occur in up to one-third of patients and care is largely supportive with a careful step-up approach to fluid collections and necrosis.

Neonatal complicated intraabdominal infection

PURPOSE OF REVIEW

The purpose of this review is to summarize the treatment of complicated intraabdominal infections (cIAIs) in premature infants.

RECENT FINDINGS

Recent work has continued to define the complex nature of cIAIs and necrotizing enterocolitis (NEC). This includes new findings on the microbiome, breast milk and risk factors associated with NEC. The treatment of cIAIs employs a combination of both surgical and medical treatment. Further look at what type and timing of surgical intervention is used as well as the ideal antibiotic regimen. Upcoming research is highlighted in future directions of NEC treatment.

SUMMARY

cIAIs in premature infants is a challenging disease with more research needed to further delineate the pathophysiology and treatment options.

Diagnostic Value and Clinical Application of Metagenomic Next-Generation Sequencing for Infections in Critically Ill Patients

Objective

To evaluate the diagnostic value and clinical application of metagenomic next-generation sequencing (mNGS) for infections in critically ill patients.

Methods

Comparison of diagnostic performance of mNGS and conventional microbiological testing for pathogens was analyzed in 234 patients. The differences between immunocompetent and immunocompromised individuals in mNGS-guided anti-infective treatment adjustment were also analyzed.

Results

The sensitivity and specificity of mNGS for bacterial and fungal detection were 96.6% (95% confidence interval [CI], 93.5%-99.6%) and 83.1% (95% CI, 75.2%-91.1%), and 85.7% (95% CI, 71.9%-99.5%) and 93.2% (95% CI, 89.7%-96.7%), respectively. Overall, 152 viruses were detected by mNGS, but in which 28 viruses were considered causative agents. The proportion of mNGS-guided beneficial anti-infective therapy adjustments in the immunocompromised group was greater than in the immunocompetent group (48.5% vs 30.1%; P=0.008). In addition, mNGS-guided anti-infective regimens with peripheral blood and BALF specimens had the highest proportion (39.0%; 40.0%), but the proportion of patients not helpful due to peripheral blood mNGS was also as high as 22.0%.

Conclusion

mNGS might be a promising technology to provide precision medicine for critically ill patients with infection.

Trends in the mortality, incidence and disability-adjusted life-years of appendicitis in EU15+ countries: an observational study of the Global Burden of Disease Database, 1990-2019

BACKGROUND

Appendicitis places a substantial burden on healthcare systems, with acute appendicitis alone being the most common abdominal surgical emergency worldwide. Further characterisation of the disease burden in EU15+ countries may help optimise the distribution of healthcare resources. The aim of this observational study was to assess the trends in mortality, incidence and disability-adjusted life-years (DALYs) of appendicitis across European Union (EU) 15+ countries between the years 1990 and 2019, Supplemental Digital Content 3, http://links.lww.com/JS9/A589 .

MATERIALS AND METHODS

Age-standardised mortality rates (ASMRs), age-standardised incidence rates (ASIRs) and DALYs data for appendicitis in males and females were extracted from the 2019 Global Burden of Disease (GBD) study. Temporal trends within the study period were analysed using Joinpoint regression analysis.

RESULTS

The median ASMRs across EU15+ countries in 2019 were 0.08/100 000 and 0.13/100 000 for females and males, respectively. Between 1990 and 2019 the median percentage change in ASMR was -52.12% for females and -53.18% in males. The median ASIRs in 2019 for females and males were 251/100 000 and 278/100 000, respectively, with a median percentage change of +7.22% for females and +3.78% for males during the observation period. Decreasing trends in DALYs were observed over the 30-year study period, with median percentage changes of -23.57% and -33.81% for females and males, respectively, Supplemental Digital Content 3, http://links.lww.com/JS9/A589 .

CONCLUSION

Overall, a general trend of decreasing appendicitis ASMRs and DALYs was observed across EU15+ countries, despite small overall increases in appendicitis ASIRs, Supplemental Digital Content 3, http://links.lww.com/JS9/A589 . Variations in both diagnostic and management strategies over the study period are likely contributory to the changing trends.

Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis

Maternal sepsis is a significant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice).

Efficacy of endoscopic ultrasound-guided pelvic abscess drainage for pelvic abscesses: A case series study

BACKGROUND AND STUDY AIM

This is a retrospective study to evaluate the safety and efficacy of endoscopic ultrasound-guided pelvic abscess drainage (EUS-PAD) in a single hospital setting.

PATIENTS AND METHODS

The referral criteria for EUS-PAD included patients with a pelvic abscess (PA) that was amenable for the procedure. A total of 14 patients with PA treated with EUS-PAD were included in this study. The mean patient age was 57.4 years, and male-to-female ratio was 7:7. Overall, there were six cases of appendiceal perforation, five of rectal cancer and one case each of the diverticular perforation, perianal abscess, and walled-off necrosis.

RESULTS

Overall, 100% of procedures were successful. Clinical success was achieved in 11 patients and they were discharged after EUS-PAD within 21.4 days on an average and the average duration of stent placement before removal was 27.0 days. Of all, six patients achieved complete improvement status where the cause was appendiceal perforation while two and one of the patients were recovered where the causes were post-curative operation for carcinoma and walled-off necrosis, respectively. Eight out of eleven patients who exhibited appendiceal perforation or underwent radical rectal cancer surgery were discharged after an average of 9.4 days post EUS-PAD. Although two patients showed temporary improvement, with perianal abscess and controlled rectal carcinoma, the PA worsened as the primary disease intensified. The PA drainage was ineffective in three patients where two of them had uncontrolled rectal cancer and one had diverticular perforation.

CONCLUSION

Conclusively, the EUS-PAD is not only a reliable, safe, and efficient alternative to surgical and percutaneous drainage but also a valuable procedure with a high success rate for patients with acute infections, such as those who have had an appendiceal perforation or curative surgery. Poor indications and contraindications for EUS-PAD include uncontrolled gastrointestinal perforation and direct tumor invasion.

Evaluation of Strategies for Reducing Vancomycin-Piperacillin/Tazobactam Incompatibility

BACKGROUND

Drug incompatibility is defined as a physical-chemical reaction between two or more injectable drugs and that results mainly in precipitation or insolubility. Several strategies for reducing incompatibilities have been implemented empirically in intensive care units. However, these strategies have never been compared directly (and particularly in terms of the particulate load and drug mass flow rate) under standardized conditions. The objective of the present in vitro study was to evaluate the impact of various strategies for preventing incompatibility between simultaneously infused vancomycin and piperacillin/tazobactam.

METHODS

An in-line filter, a dilute vancomycin solution (5 mg/mL), and an alternative saline administration line were evaluated separately. The infusion line outlet was connected to a dynamic particle counter. The antibiotic concentration was measured in an HPLC-UV assay.

RESULT

The use of an in-line filter and an alternative saline administration route did not significantly reduce the particulate load caused by vancomycin-piperacillin/tazobactam incompatibility. Dilution of the vancomycin solution was associated with a significantly lower particulate load and maintenance of the vancomycin mass flow rate.

DISCUSSION

It is important to systematically compare the efficacy of strategies for preventing drug incompatibility. The use of diluted vancomycin solution gave the best results in the case of vancomycin-piperacillin/tazobactam incompatibility.

Contemporary pharmacologic treatments of MRSA for hospitalized adults: rationale for vancomycin versus non-vancomycin therapies as first line agents

INTRODUCTION

Methicillin-resistant Staphylococcus aureus (MRSA) remains an important pathogen in the hospital setting and causes significant morbidity and mortality each year. Since the initial discovery over 60 years ago, vancomycin has remained a first-line treatment for many different types of MRSA infections. However, significant concerns related to target attainment and nephrotoxicity have spurred efforts to develop more effective agents in the last two decades.

AREAS COVERED

Newer anti-MRSA antibiotics that have been approved since 2000 include linezolid, daptomycin, and ceftaroline. As clinical evidence has accumulated, these newer agents have become more frequently used, and some are now recommended as co-first-line options (along with vancomycin) in clinical practice guidelines. For this review, a scoping review of the literature was conducted to support our findings and recommendations.

EXPERT OPINION

Vancomycin remains an important standard of care for MRSA infections but is limited with respect to nephrotoxicity and rapid target attainment. Newer agents such as linezolid, daptomycin, and ceftaroline have specific indications for treating different types of MRSA infections; however, newer agents also have unique attributes which require consideration during therapy.

Safety and Efficacy of Ceftolozane/Tazobactam Plus Metronidazole Versus Meropenem From a Phase 2, Randomized Clinical Trial in Pediatric Participants With Complicated Intra-abdominal Infection

BACKGROUND

Ceftolozane/tazobactam, a cephalosporin-β-lactamase inhibitor combination, is approved for the treatment of complicated urinary tract infections and complicated intra-abdominal infections (cIAI). The safety and efficacy of ceftolozane/tazobactam in pediatric participants with cIAI were assessed.

METHODS

This phase 2 study (NCT03217136) randomized participants to either ceftolozane/tazobactam+metronidazole or meropenem for treatment of cIAI in pediatric participants (<18 years). The primary objective was to assess the safety and tolerability of intravenous ceftolozane/tazobactam+metronidazole. Clinical cure at end of treatment (EOT) and test of cure (TOC) visits were secondary end points.

RESULTS

The modified intent-to-treat (MITT) population included 91 participants (ceftolozane/tazobactam+metronidazole, n = 70; meropenem, n = 21). Complicated appendicitis was the most common diagnosis (93.4%); Escherichia coli was the most common pathogen (65.9%). Adverse events (AEs) occurred in 80.0% and 61.9% of participants receiving ceftolozane/tazobactam+metronidazole and meropenem, drug-related AEs occurred in 18.6% and 14.3% and serious AEs occurred in 11.4% and 0% of participants receiving ceftolozane/tazobactam+metronidazole and meropenem, respectively. No drug-related serious AEs or discontinuations due to drug-related AEs occurred. Rates of the clinical cure for ceftolozane/tazobactam+metronidazole and meropenem at EOT were 80.0% and 95.2% (difference: -14.3; 95% confidence interval: -26.67 to 4.93) and at TOC were 80.0% and 100.0% (difference: -19.1; 95% confidence interval: -30.18 to -2.89), respectively; 6 of the 14 clinical failures for ceftolozane/tazobactam+metronidazole at TOC were indeterminate responses imputed as failures per protocol.

CONCLUSION

Ceftolozane/tazobactam+metronidazole was well tolerated in pediatric participants with cIAI and had a safety profile similar to the established safety profile in adults. In this descriptive efficacy analysis, ceftolozane/tazobactam+metronidazole appeared efficacious.

Relationship between COVID-19 and ICU-acquired colonization and infection related to multidrug-resistant bacteria: a prospective multicenter before-after study

PURPOSE

Patients presenting the most severe form of coronavirus disease 2019 (COVID-19) pneumonia, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have a prolonged intensive care unit (ICU) stay and are exposed to broad-spectrum antibiotics, but the impact of COVID-19 on antimicrobial resistance is unknown.

METHODS

Observational prospective before-after study in 7 ICUs in France. All consecutive patients with an ICU stay > 48 h and a confirmed SARS-CoV-2 infection were included prospectively and followed for 28 days. Patients underwent systematic screening for colonization with multidrug-resistant (MDR) bacteria upon admission and every week subsequently. COVID-19 patients were compared to a recent prospective cohort of control patients from the same ICUs. The primary objective was to investigate the association of COVID-19 with the cumulative incidence of a composite outcome including ICU-acquired colonization and/or infection related to MDR bacteria (ICU-MDR-col and ICU-MDR-inf, respectively).

RESULTS

From February 27th, 2020 to June 2nd, 2021, 367 COVID-19 patients were included, and compared to 680 controls. After adjustment for prespecified baseline confounders, the cumulative incidence of ICU-MDR-col and/or ICU-MDR-inf was not significantly different between groups (adjusted sub-hazard ratio [sHR] 1.39, 95% confidence interval [CI] 0.91-2.09). When considering both outcomes separately, COVID-19 patients had a higher incidence of ICU-MDR-inf than controls (adjusted sHR 2.50, 95% CI 1.90-3.28), but the incidence of ICU-MDR-col was not significantly different between groups (adjusted sHR 1.27, 95% CI 0.85-1.88).

CONCLUSION

COVID-19 patients had an increased incidence of ICU-MDR-inf compared to controls, but the difference was not significant when considering a composite outcome including ICU-MDR-col and/or ICU-MDR-inf.

[Primary pneumococcal peritonitis in a pediatric hospital from Argentina]

Pneumococcal peritonitis represents a small subset of patients suffering from invasive pneumococcal disease (IPD). We describe 5 cases of primary peritonitis documented in the pediatric hospital over 15 years (2005-2020) of IPD surveillance. The patients, 3girls and 2boys with a mean age of 5 years, experienced peritoneal signs and symptoms; 3of them suffered from nephrotic syndrome. Based on the local resistance profiles, all isolates were sensitive to beta-lactams, one strain showed resistance to cotrimoxazole and tetracycline while another strain, to cotrimoxazole only. Serotypes found in 4/5 strains (one was non-viable) were: 1, 19F, 15C and 23A. Children were treated with third-generation cephalosporins or ampicillin, gentamicin and metronidazole and all of them evolved favorably. Pneumococcal etiology should be included in the differential diagnosis of acute abdominal pain in children. Our study aims to contribute to the knowledge of this condition and to the local epidemiology of IPD.

Mortality Risk Prediction in Abdominal Septic Shock Treated with Polymyxin-B Hemoperfusion: A Retrospective Cohort Study

Endotoxin, a component of the cell membrane of gram-negative bacteria, is a trigger for dysregulated inflammatory response in sepsis. Extracorporeal purification of endotoxin, through adsorption with polymyxin B, has been studied as a therapeutic option for sepsis. Previous studies suggest that it could be effective in patients with high endotoxin levels or patients with septic shock of moderate severity. Here, we perform a retrospective, single-centre cohort study of 93 patients suffering from abdominal septic shock treated with polymyxin-B hemoperfusion (PMX-HP) between 2015 and 2020. We compared deceased and surviving patients one month after the intervention using X² and Mann-Whitney U tests. We assessed the data before and after PMX-HP with a Wilcoxon single-rank test and a multivariate logistic regression analysis. There was a significant reduction of SOFA score in the survivors. The expected mortality using APACHE-II was 59.62%, whereas in our sample, the rate was 40.9%. We found significant differences between expected mortality and real mortality only for the group of patients with an SOFA score between 8 and 13. In conclusion, in patients with abdominal septic shock, the addition of PMX-HP to the standard therapy resulted in lower mortality than expected in the subgroup of patients with intermediate severity of illness.

Carbapenem Antibiotics Versus Other Antibiotics for Complicated Intra-abdominal Infections: a Systematic Review and Patient-Level Meta-analysis of Randomized Controlled Trials (PROSPERO CRD42018108854)

BACKGROUND

The treatment of complicated intra-abdominal infections remains a challenge. Both optimal medical and surgical therapy (i.e., source control) are needed to achieve low mortality and morbidity. The objective of this systematic review and meta-analysis is to determine the impact of carbapenem antibiotic therapy compared to other antibiotics in complicated intra-abdominal infections (secondary peritonitis) with an emphasis on mortality and postoperative complications.

METHODS

A systematic literature search from PubMed/Medline and Web of Science databases was carried out. The last search was conducted in August 2022. PRISMA guidelines were followed. Pre-defined outcomes were mortality, treatment success, treatment failure, and adverse events.

RESULTS

Ten randomized controlled trials, published from 1983 to 2013 with a total of 2377 patients (1255 patients in the carbapenem antibiotics group and 1122 in the control group), were identified. A meta-analysis comparing patients undergoing carbapenem antibiotic therapy and patients receiving other antibiotics was performed. No significant difference regarding mortality (OR 1.19, 95% CI [0.79; 1.82], p = 0.40), treatment success (OR 1.17, 95% CI [0.72; 1.91], p = 0.53), and treatment failure (OR 0.84, 95% CI [0.48; 1.45], p = 0.52) was observed. Carbapenem therapy was associated with fewer adverse events compared to therapy with other antibiotics (OR 0.79, 95% CI [0.65; 0.97], p = 0.022).

CONCLUSION

There is currently no evidence that carbapenem antibiotics are superior in terms of mortality, and success or failure for the treatment of complicated intra-abdominal infections (secondary peritonitis). The rate of adverse events is lower under carbapenem therapy compared to control antibiotics.

TRIAL REGISTRATION

PROSPERO 2018 CRD42018108854.

Antibiotic therapy and necrotizing enterocolitis

Antibiotic therapy remains a cornerstone of treatment of both medical and surgical presentations of necrotizing enterocolitis (NEC). However, guidelines regarding the administration of antibiotics for the treatment of NEC are lacking and practices vary amongst clinicians. Although the pathogenesis of NEC is unknown, there is consensus that the infant gastrointestinal microbiome contributes to the disease. The presumed connection between dysbiosis and NEC has prompted some to study whether early prophylactic enteral antibiotics can prevent NEC. Yet others have taken an opposing approach, studying whether perinatal antibiotic exposure increases the risk of NEC by inducing a state of dysbiosis. This narrative review summarizes what is known about antibiotics and their association with the infant microbiome and NEC, current antibiotic prescribing practices for infants with medical and surgical NEC, as well as potential strategies to further optimize the use of antibiotics in this population of infants.

Analysis of cumulative antibiogram reports in intensive care units at an Egyptian University Hospital

BACKGROUND

Institutions must have access to antibiograms to monitor changes in antimicrobial resistance and direct empirical antibiotic therapy. The first facility-specific cumulative antibiogram was launched in the ICU in 2019. Consequently, many antibiogram-operation-related actions have been adopted in the institution based on reported data. This study aimed to analyze the cumulative antibiogram reports for multiple intensive care units (ICUs) for 2020, and compare the antimicrobial susceptibility testing (AST) patterns between the 2019 and 2020 years in an academic medical center.

METHODS

This cross-sectional study was performed of routine bacterial culture and AST data extracted from a laboratory information system in a 2252-bed capacity hospital. Only the first diagnostic isolate of a given species per patient per year was included in the study. Interpretation and reporting were done in accordance with the applicable Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing guidelines.

RESULTS

Of the 46,791 clinical isolates, the Gram-negative bacilli isolation rate witnessed a significant increase: 35,670 isolates in 2020 versus. 33,652 isolates in 2019. Klebsiella pneumoniae showed a statistically significant increase, mainly in pediatric, emergency, and cardiothoracic ICUs (p < 0.001). Neonatal and pediatric ICUs showed statistically significant increases in Pseudomonas aeruginosa and Proteus mirabilis isolates (p < 0.001). A statistically significant decrease was noted in the prevalence of Acinetobacter, Escherichia coli, Burkholderia cepacia, and Enterobacter cloacae. The sensitivities of K. pneumoniae and E. coli to imipenem and tigecycline significantly improved (p < 0.001). The sensitivity to colistin was significantly decreased (p < 0.001). The sensitivity of P. aeruginosa isolates to colistin and carbapenems was improved (p < 0.001). We reported a statistically significant decrease in all Gram-positive cocci (11,121 in 2020 versus. 11,528 in 2019). Staphylococcus aureus showed a statistically significant increase (p < 0.001), particularly in the medical ICU.

CONCLUSION

The high susceptibility rates of Enterobacteriaceae toward colistin and tigecycline, should be cautiously considered in empiric therapy while looking for alternatives. The majority of isolates of Gram-positive cocci were coagulase negative staphylococci (CONS), we still need to confirm whether they are true pathogens or commensals before considering anti-staphylococcal agents in the empirical therapy. We underscored some corrective actions that might have improved the susceptibility rates, such as antibiotic cycling.

Clinical characteristics and predictive factors of postoperative intra-abdominal abscess after distal pancreatectomy

PURPOSE

The postoperative mortality rate of distal pancreatectomy is lower than that of pancreaticoduodenectomy, although persistent complications may occur after distal pancreatectomy. Fluid collection (FC) is frequently observed after distal pancreatectomy; however, FC may occasionally progress to postoperative intra-abdominal abscess (PIAA), which requires conservative or progressive interventional treatment. This study aimed to compare the status between patients with or without PIAA, identify predictive factors for PIAA and clinically relevant postoperative pancreatic fistula, and investigate the clinical characteristics of patients with PIAA with interventional drainage.

METHODS

We retrospectively reviewed data of patients who underwent distal pancreatectomy between January 2012 and December 2019 at two high-volume centers, where hepatobiliary-pancreatic surgeries were performed by expert specialist surgeons. Logistic regression analysis was performed to determine the predictive factors for PIAA.

RESULTS

Overall, 242 patients were analyzed, among whom 49 (20.2%) had PIAA. The median postoperative period of PIAA formation was 9 (range: 3-49) days. Among the 49 patients with PIAA, 25 (51.0%) underwent percutaneous ultrasound, computed tomography, or endoscopic ultrasound-guided interventions for PIAA. In the univariate analysis, preoperative indices representing abdominal fat mass (i.e., body mass index, subcutaneous fat area, and visceral fat area) were identified as predictive factors for PIAA; in the multivariate analysis, C-reactive protein (CRP) level (continuous variable) on postoperative day (POD) 3 (odds ratio: 1.189, 95.0% confidence interval: 1.111 - 1.274; P < 0.001) was the only independent and significant predictive factor for PIAA.

CONCLUSIONS

CRP level on POD 3 was an independent and significant predictive factor for PIAA after distal pancreatectomy.

Consecutive antibiotic shortages highlight discrepancies between microbiology and prescribing practices for intra-abdominal infections

Piperacillin-tazobactam (TZP) is frequently used for intra-abdominal infection (IAI). Our institution experienced consecutive shortages of TZP and cefepime, providing an opportunity to review prescribing patterns and microbiology for IAI. Hospitalized adult patients treated for IAI, based on provider selection of IAI as the indication within the antibiotic order, between March 2014 and February 2018 were identified from the University of Virginia Clinical Data Repository and Infection Prevention and Control Database. Antimicrobial utilization, microbiologic data, and clinical outcomes were compared across four year-long periods: pre-shortage, TZP shortage, cefepime shortage, and post-shortage. There were 7,668 episodes of antimicrobial prescribing for an indication of IAI during the study period. Cefepime use for IAI increased 190% during the TZP shortage; meanwhile ceftriaxone use increased by only 57%. There was no increase in in-house mortality, colonization with resistant organisms, or Clostridiodes difficile infection among patients treated with IAI during the shortage periods. Among a subset of cases randomly selected for review, Pseudomonas sp. was a rare cause of IAI, but anti-pseudomonal antibiotics were commonly prescribed empirically. We observed a large increase in cefepime utilization for IAI during a TZP shortage that was not warranted based on the observed frequency of identification of Pseudomonas sp. as the causative organism in IAI, suggesting a need to revisit national guideline recommendations.

2023 Update on Sepsis and Septic Shock in Adult Patients: Management in the Emergency Department

BACKGROUND

Sepsis/septic shock is a life-threatening and time-dependent condition that requires timely management to reduce mortality. This review aims to update physicians with regard to the main pillars of treatment for this insidious condition.

METHODS

PubMed, Scopus, and EMBASE were searched from inception with special attention paid to November 2021-January 2023.

RESULTS

The management of sepsis/septic shock is challenging and involves different pathophysiological aspects, encompassing empirical antimicrobial treatment (which is promptly administered after microbial tests), fluid (crystalloids) replacement (to be established according to fluid tolerance and fluid responsiveness), and vasoactive agents (e.g., norepinephrine (NE)), which are employed to maintain mean arterial pressure above 65 mmHg and reduce the risk of fluid overload. In cases of refractory shock, vasopressin (rather than epinephrine) should be combined with NE to reach an acceptable level of pressure control. If mechanical ventilation is indicated, the tidal volume should be reduced from 10 to 6 mL/kg. Heparin is administered to prevent venous thromboembolism, and glycemic control is recommended. The efficacy of other treatments (e.g., proton-pump inhibitors, sodium bicarbonate, etc.) is largely debated, and such treatments might be used on a case-to-case basis.

CONCLUSIONS

The management of sepsis/septic shock has significantly progressed in the last few years. Improving knowledge of the main therapeutic cornerstones of this challenging condition is crucial to achieve better patient outcomes.

Population Pharmacokinetics and AUC-Guided Dosing of Tobramycin in the Treatment of Infections Caused by Glucose-Nonfermenting Gram-Negative Bacteria

PURPOSE

Tobramycin (TOB) exhibits variable pharmacokinetic properties due to the clinical condition of patients. This study aimed to investigate the AUC-guided dosing of TOB based on population pharmacokinetic analysis in the treatment of infections caused by Pseudomonas aeruginosa, Acinetobacter baumannii, and Stenotrophomonas maltophilia.

METHODS

This retrospective study was conducted between January 2010 and December 2020 after obtaining approval from our institutional review board. For 53 patients who received therapeutic drug monitoring of TOB, a population pharmacokinetic model was developed with covariates of estimated glomerular filtration rate using serum creatinine (eGFRcre) on clearance (CL) and weight on both CL and V_d in exponential error modeling (CL = 2.84 × [weight/70] × eGFRcre^0.568, interindividual variability [IIV] = 31.1%; V_d = 26.3 × [weight/70], IIV = 20.2%; residual variability = 28.8%).

FINDINGS

The final regression model for predicting 30-day mortality was developed with risk factors of AUC during a 24-hour period after the first dose to MIC ratio (odds ratio [OR] = 0.996; 95% CI, 0.968-1.003) and serum albumin (OR = 0.137; 95% CI, 0.022-0.632). The final regression model for predicting acute kidney injury was developed with the risk factors of C-reactive protein (OR = 1.136; 95% CI, 1.040-1.266) and AUC during a 72-hour period after the first dose (OR = 1.004; 95% CI, 1.000-1.001). A dose of 8 or 15 mg/kg was beneficial for achievement of AUC during a 24-hour period after the first dose/MIC >80 and trough concentration <1 µg/mL in patients with preserved kidney function and TOB CL >4.47 L/h/70 kg in the events of MIC of 1 or 2 µg/mL, respectively. We propose that the first dose of 15, 11, 10, 8, and 7 mg/kg for eGFRcre >90, 60 to 89, 45 to 59, 30 to 44, and 15 to 29 mL/min/1.73 m² be followed by therapeutic drug monitoring at peak and 24 hours after the first dose.

IMPLICATIONS

This study suggests that TOB use encourages the replacement of trough- and peak-targeted dosing with AUC-guided dosing.

Efficacy, safety, and tolerability of antimicrobial agents for complicated intra-abdominal infection: a systematic review and network meta-analysis

BACKGROUND

Which antimicrobial agents provide the optimal efficacy, safety, and tolerability for the empirical treatment of complicated intra-abdominal infection (cIAI) remains unclear but is paramount in the context of evolving antimicrobial resistance. Therefore, updated meta-analyses on this issue are warranted.

METHODS

We systematically searched four major electronic databases from their inception through October 2022. Randomized controlled trials examining antimicrobial agents for cIAI treatment were included. Two reviewers independently assessed the quality of included studies utilizing the Cochrane Collaboration's risk of bias tool as described in the updated version 1 of the Cochrane Collaboration Handbook and extracted data from all manuscripts according to a predetermined list of topics. All meta-analyses were conducted using R software. The primary outcome was clinical success rate in patients with cIAIs.

RESULTS

Forty-five active-controlled trials with low to medium methodological quality and involving 14,267 adults with cIAIs were included in the network meta-analyses. The vast majority of patients with an acute physiology and chronic health evaluation II score < 10 had low risk of treatment failure or death. Twenty-one regimens were investigated. In the network meta-analyses, cefepime plus metronidazole was more effective than tigecycline and ceftolozane/tazobactam plus metronidazole (odds ratio [OR] = 1.96, 95% credibility interval [CrI] 1.05 ~ 3.79; OR = 3.09, 95% CrI 1.02 ~ 9.79, respectively). No statistically significant differences were found among antimicrobial agents regarding microbiological success rates. Cefepime plus metronidazole had lower risk of all-cause mortality than tigecycline (OR = 0.22, 95% CrI 0.05 ~ 0.85). Statistically significant trends were observed favoring cefotaxime plus metronidazole, which exhibited fewer discontinuations because of adverse events (AEs) when compared with eravacycline, meropenem and ceftolozane/tazobactam plus metronidazole (OR = 0.0, 95% CrI 0.0 ~ 0.8; OR = 0.0, 95% CrI 0.0 ~ 0.7; OR = 0.0, 95% CrI 0.0 ~ 0.64, respectively). Compared with tigecycline, eravacycline was associated with fewer discontinuations because of AEs (OR = 0.17, 95% CrI 0.03 ~ 0.81). Compared with meropenem, ceftazidime/avibactam plus metronidazole had a higher rate of discontinuation due to AEs (OR = 2.09, 95% CrI 1.0 ~ 4.41). In pairwise meta-analyses, compared with ceftriaxone plus metronidazole, ertapenem and moxifloxacin (one trial, OR = 1.93, 95% CI 1.06 ~ 3.50; one trial, OR = 4.24, 95% CI 1.18 ~ 15.28, respectively) were associated with significantly increased risks of serious AEs. Compared with imipenem/cilastatin, tigecycline (four trials, OR = 1.57, 95%CI 1.07 ~ 2.32) was associated with a significantly increased risk of serious AEs. According to the surface under the cumulative ranking curve, Cefepime plus metronidazole was more likely to be optimal among all treatments in terms of efficacy and safety, tigecycline was more likely to be worst regimen in terms of tolerability, and eravacycline was more likely to be best tolerated.

CONCLUSION

This study suggests that cefepime plus metronidazole is optimal for empirical treatment of patients with cIAIs and that tigecycline should be prescribed cautiously considering the safety and tolerability concerns. However, it should be noted that data currently available on the effectiveness, safety, and tolerability of antimicrobial agents pertain mostly to lower-risk patients with cIAIs.

Pyoperitoneum as a consequence of perinephric abscess spontaneous rupture. A case report

Intra-abdominal infections are a common cause of severe sepsis and have a significantly high morbidity and mortality rate. Patients continue to present to hospitals with unacceptable delays in diagnosis or management, resulting in sepsis and organ failure, which lower their survival chances. We reported a rare case of a 64-year-old Syrian woman with a spontaneous rupture of a perinephric abscess that resulted in intra-abdominal infection and ascites, which led to sepsis and multiple organ failure despite resuscitation and antibiotic treatment according to guidelines. Although the recommendations for patients with intra-abdominal infection and hemodynamic instability differ, there is an agreement that surgery should be considered early when other interventional approaches have failed. Rupture of the perinephric abscess rarely produces intra-abdominal infection and ascites; effective care requires early and appropriate infection source identification. To avoid delays, doctors need to use academic methods in developing diagnoses and management.

High risk and low prevalence diseases: Mesenteric ischemia

INTRODUCTION

Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment.

CONCLUSIONS

An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.

Prevalence of antimicrobial resistant genes in Bacteroides spp. isolated in Oita Prefecture, Japan

INTRODUCTION

Bacteroides spp. are the most common anaerobic bacteria isolated from the human gastrointestinal tract. Several resistant genes are present in Bacteroides spp. However, most studies have focused on the prevalence of the cfiA gene in Bacteroides fragilis alone. We assessed the susceptibility to antimicrobial agents and the prevalence of cepA, cfiA, cfxA, ermF, nim, and tetQ genes in Bacteroides strains isolated from clinical specimens in our hospital.

METHODS

We isolated 86 B. fragilis and 58 non-fragilis Bacteroides strains from human clinical specimens collected from January 2011 to November 2021. Resistance against piperacillin (PIPC), cefotaxime (CTX), cefepime (CFPM), meropenem (MEPM), clindamycin, and minocycline was determined.

RESULTS

The resistant rates of penicillins and cephalosporins in non-fragilis isolates were significantly higher than those in B. fragilis isolates. In B. fragilis isolates, the resistant rates of PIPC, CTX, and CFPM in cfxA-positive isolates were significantly higher than those in cfxA-negative isolates (71% vs. 16%, 77% vs. 19%, and 77% vs. 30%, respectively). Thirteen B. fragilis isolates harbored the cfiA gene, two of which were resistant to MEPM. Six of the 13 cfiA-positive B. fragilis isolates were heterogeneously resistant to MEPM.

CONCLUSION

It is important to evaluate the use of MEPM as empirical therapy for Bacteroides spp. infections, considering the emergence of carbapenem resistance during treatment, existence of MEPM-resistant strains, and heterogeneous resistance.

Bacterial infections and antibiotic utilization varies by coronavirus disease 19 (COVID-19) severity in hospitalized cancer patients: Analysis from the first phase of the pandemic

OBJECTIVE

To characterize bacterial infections and antibiotic utilization in hospitalized cancer patients with coronavirus disease 2019 (COVID-19).

DESIGN

Retrospective cohort study.

SETTING

Tertiary cancer center in New York City.

PATIENTS

Hospitalized cancer patients ≥18 years with COVID-19 between March 1, 2020, and May 31, 2020.

METHODS

Patients were classified with mild COVID-19 (ie, with room air), moderate COVID-19 (ie, using nasal cannula oxygen), or severe COVID-19 (ie, using high-flow oxygen or mechanical ventilation). The primary outcome was bacterial infection rate within 30 days of COVID-19 onset. Secondary outcomes included the proportion of patients receiving antibiotics and antibiotic length of therapy (LOT).

RESULTS

Of 358 study patients, 133 had mild COVID-19, 97 had moderate COVID-19, and 128 had severe COVID-19. Of 358 patients, 234 (65%) had a solid tumor. Also, 200 patients (56%) had 245 bacterial infections, of which 67 (27%) were microbiologically confirmed. The proportion of patients with bacterial infection increased with COVID-19 severity: mild (n = 47, 35%) versus moderate (n = 49, 51%) versus severe (n = 104, 81%) (P < .0001). Also, 274 (77%) received antibiotics for a median of 4 days. The median antibiotic LOTs were 7 days with 1 infection and 20 days with multiple infections (P < .0001). Antibiotic durations were 1 day for patients with mild COVID-19, 4 days for patients with moderate COVID-19, and 8 days for patients with severe COVID-19 (P < .0001).

CONCLUSIONS

Hospitalized cancer patients with COVID-19 had a high rate of bacterial infection. As COVID-19 severity increased, the proportion of patients diagnosed with bacterial infection and given antibiotics increased. In mild COVID-19 cases, antibiotic LOT was short, suggesting that empiric antibiotics can be safely avoided or discontinued in this group.

Assessment of antibiotic prescribing patterns at dental and primary health care clinics according to WHO Access, Watch, Reserve (AWaRe) classification

BACKGROUND

The 2019 WHO Access, Watch, Reserve (AWaRe) antibiotic classification framework aims to prevent irrational prescribing of antibiotics used to treat widespread infections. This study explored antibiotic prescribing pattern for appropriate indications by family physicians and general dentists in primary health care practices.

METHODS

A retrospective review of patients' electronic medical records was conducted over 6 months, from May 1, 2020, to November 30, 2020. The data were collected from 24 general family medicine and dental practices within the North West Armed Forces in Tabuk city. Antibiotic prescribing for systemic use (J01) was assessed by the number of prescriptions and the number defined daily doses (DDDs) and then analyzed according to the AWaRe classification. The prescribing of antibiotics for appropriate indications was assessed through comparing the prescription pattern with the recently published and relevant clinical guidelines. Multivariate logistic regression analysis was used to predict the association between the prescribing of AWaRe category and some demographic and disease-related factors.

RESULTS

In total, 752 prescriptions of antibiotics were collected. Watch-group antibiotics such as second-generation cephalosporin and macrolides were more likely prescribed (51.1%) based on the number of prescriptions and (52.2%) based on DDDs compared with Access-group antibiotics (48.9%) and (47.8%), respectively. The percentages of Watch group antibiotics for children and adults were 66.7% and 42.9%, respectively. Adherence to prescribing guidelines was poor for children (27.2%) and adults (64%). Being a child (adjusted odds ratio [OR]: 2.89; 95% confidence interval [CI] = 1.46-5.78), diagnosis with acute respiratory tract infection (adjusted OR, 2.62; 95% CI = 1.03-6.69), and urinary tract infection (adjusted OR, 4.69; 95% CI = 2.09-10.56) were associated with higher prescriptions of Watch-group antibiotics.

CONCLUSIONS

a higher prescribing of Watch-group antibiotics and poor adherence to antibiotic guidelines were observed, especially for children. The findings of this study identified targets for further improvement and interventions needed to develop better antibiotic-prescribing practices.

Comprehensive Diagnosis and Management of Malignant Bowel Obstruction: A Review

Malignant bowel obstruction is a common complication of advanced gastrointestinal, gynecologic, and genitourinary tumors. Patients present with nausea, vomiting, abdominal pain, and constipation. Cross-sectional imaging is essential to make a diagnosis of bowel obstruction. Initial management is conservative with fluid replacement, electrolyte replacement, bowel rest and sometimes nasogastric decompression. Numerous advanced options exist for definitive management, though none are overly promising but nevertheless may improve quality and quantity of life. Surgical bypass, endoscopic stenting, and endoscopic decompression are some of the options with variable efficacy and are employed in select patients. Chemotherapy may be utilized if the bowel obstruction resolves to reduce tumor burden in a limited number of patients. Parenteral nutrition is an option and should typically be used in surgical patients with good functional and nutritional status with limited tumor burden or curative intent. Palliative care and hospice should be discussed in patients with advanced malignancy who present with peritoneal carcinomatosis or multiple levels of obstruction. Overall prognosis of malignant bowel obstruction is poor, and median survival ranges from 26 to 192 days.

A Six-Year Retrospective Study of Microbiological Characteristics and Antimicrobial Resistance in Specimens from a Tertiary Hospital’s Surgical Ward

Surgery has revolutionized the practice of medicine by allowing the treatment of conditions amenable to conservative medical management with some of them pathophysiologically involving the prevalence of pathogenic microorganisms. On the other hand, infections such as surgical site infections or urinary tract infections may complicate patients hospitalized in surgical wards leading to considerable morbidity, mortality, and increased healthcare-associated costs. The aim of this study was to present the microbiological characteristics and antimicrobial resistance of all isolates identified in microbiological specimens from a surgical ward of a tertiary hospital in Greece during a six-year period. Only specimens that yielded at least one microorganism were included in the analysis. In total, 1459 strains in 789 positive cultures were isolated. The most common sample sent to the microbiology department was pus from surgical wounds. The most common pathogens among all 1459 strains isolated were Enterobacterales at 33% (n = 482), however, the most common genus was Enterococcus at 22.3% (n = 326). Antimicrobial resistance against third-generation cephalosporins was 23% (n = 111/482) among Enterobacterales, while, the rate of vancomycin-resistant enterococci (VRE) was 18.5% (n = 60/324) among Enterococcus species and was increasing in the last years of the study. Antimicrobial resistance of Acinetobacter baumannii to carbapenems was 68.8% (n = 11/16), which was lower than the corresponding rate in other wards in Greece. The antimicrobial resistance rates noted herein raise questions regarding the appropriateness of currently suggested antimicrobials in guidelines and imply that a revision could be required. Practicing clinicians should always be aware of local microbiological data that allow the selection of appropriate antimicrobials for the management of infections. Finally, the increasing rates of VRE noted herein mandate further actions from the point of infection control and antimicrobial stewardship.

Antibiotic treatment durations for common infectious diseases in Switzerland: comparison between real-life and local and international guideline recommendations

OBJECTIVES

Shortening the duration of antibiotic therapy (DAT) for common infectious diseases may be an effective strategy to tackle antimicrobial resistance. Shorter DAT has been proven safe and effective for community-acquired pneumonia (CAP), cellulitis, and cholangitis.

METHODS

In a retrospective multicentre quality-control study, medical records of 770 patients hospitalized with CAP, cellulitis, and cholangitis at three tertiary care hospitals in Switzerland during 2017-2018 were randomly selected. Appropriateness of antibiotic treatment duration was assessed according to international and local guidelines.

RESULTS

Records of 271, 260, and 239 patients with CAP, cellulitis, and cholangitis were included, respectively. Median DAT was seven days (interquartile range [IQR] 6-9), ten days (IQR 8-13), and nine days (IQR 6-13) in CAP, cellulitis, and cholangitis, respectively. DAT longer than recommended by local and international guidelines was observed in 32% and 37% of CAP patients, 23% and 70% of cellulitis patients, and 33% and 37% of cholangitis patients, respectively. Positive blood cultures (odds ratio [OR] = 2.42 (95% confidence interval [CI] 1.33-4.34]), infectious diseases consultation (OR = 1.79 [95% CI 1.05-2.78]), impaired renal function (OR = 0.99 [95% CI 0.98-1.00] per 1 ml/min / 1.73 m² increase in estimated glomerular filtration rate) and a higher degree of inflammation on admission (OR = 1.0 [95% CI 1.001-1.005] per 10 mg/L increase in C-reactive protein) were independently associated with a DAT longer than recommended in international guidelines.

CONCLUSIONS

DAT exceeded recommendations in a significant proportion of patients with mostly community-acquired infections.

Pediatric Appendicitis Transfers From Adult Centers: Can Alvarado Scores Help Determine Which Patients Need a CT?

BACKGROUND

Acute appendicitis is possible for any pediatric patient with abdominal pain. At our tertiary care center, patients are transferred for surgical management with unnecessary or excessive imaging. We hypothesize that using the Alvarado score (AS) to clinically stage patients will identify patient groups that could be transferred prior to imaging.

METHODS

Retrospective review of pediatric patients transferred to our hospital for suspected appendicitis between 11/2020 and 3/2022 was performed. Variables collected included AS, imaging, and pathology. Alvarado score was calculated for each patient, and patients were grouped into low score, intermediate score, and high score groups. Positive predictive values (PPVs) were calculated for patients who underwent CT.

RESULTS

196 patients (age 2-17, 58% male) were transferred with suspected appendicitis. CT was obtained in 67% of patients and was not significantly different between groups. The low-score group (n=35) had a rate of appendicitis of 14% and the PPV of CT was 33%. The intermediate-score group (n = 74) had a rate of appendicitis of 62% and the PPV of CT was 88%. In the high-score group (n = 87), the rate of appendicitis was 92% and PPV of CT was 98%.

DISCUSSION

Our data show that patients with low, intermediate, and high AS undergo CT at similar rates. We suggest that patients in the low score and high score groups may not benefit from reflexive CT given the likelihood of appendicitis based on the Alvarado score. We propose that CT in these groups be performed at the discretion of the pediatric center in order to expedite transfer and spare children excess radiation.

Rapid Detection of Piperacillin-Tazobactam Resistance in Klebsiella pneumoniae and Escherichia coli

Rapid determination of susceptibility to piperacillin-tazobactam (TZP) is very important since the development of antibiotic resistance and inadequate treatment could increase the risk of clinical failure in infected patients, especially if such resistance is unknown to the clinician. Therefore, based on color change from orange to yellow of phenol red due to glucose metabolism (bacterial growth) in the presence of an adequate concentration of TZP (10 mg/L piperacillin and 5 mg/L tazobactam), the RapidTZP test has been developed to detect TZP resistance in Escherichia coli and Klebsiella pneumoniae isolates in a maximum of 3 h. A total of 140 isolates, 43 of E. coli and 97 of K. pneumoniae, were used to evaluate the performance of the test, 60 being resistant to TZP. The sensitivity and specificity of the test were 98.24% and 100%, respectively. Additionally, the RapidTZP test was validated by a pellet obtained directly from blood culture bottles. A total of 37 positive blood cultures for E. coli and 43 for K. pneumoniae were used for validation, 8 of them resistant to TZP. The sensitivity and specificity shown in the evaluation were 100% for both parameters. This new test is easy, fast, and accurate, providing results in 3 h. IMPORTANCE TZP is an antibiotic widely used for the empirical treatment of severe infections such as bloodstream infections. However, resistance to TZP in K. pneumoniae and E. coli has been increasing in the last few years. Thus, rapid detection of TZP resistance is critical to optimize the empirical treatment of patients with severe infections. In this study, we developed and evaluated a rapid test (RapidTZP) for the detection of TZP resistance in K. pneumoniae and E. coli directly from positive hemocultures in just 3 h. This rapid test has been validated on 138 K. pneumoniae and E. coli clinical isolates directly from agar plates and 80 K. pneumoniae and E. coli isolates causing bloodstream infections. The results demonstrate that the RapidTZP test has great clinical potential to optimize the empirical treatment of patients with bloodstream infections.

Relationship between immunosuppression and intensive care unit-acquired colonization and infection related to multidrug-resistant bacteria: a prospective multicenter cohort study

PURPOSE

The impact of immunosuppression on intensive care unit (ICU)-acquired colonization and infection related to multidrug-resistant (MDR) bacteria (ICU-MDR-col and ICU-MDR-inf, respectively) is unknown.

METHODS

We carried out an observational prospective cohort study in 8 ICUs in France (all with single-bed rooms and similar organizational characteristics). All consecutive patients with an ICU stay > 48 h were included, regardless of immune status, and followed for 28 days. Patients underwent systematic screening for colonization with MDR bacteria upon admission and every week subsequently. Immunosuppression was defined as active cancer or hematologic malignancy, neutropenia, solid-organ transplant, use of steroids or immunosuppressive drugs, human immunodeficiency virus infection and genetic. The primary endpoint was the incidence rate of a composite outcome including ICU-MDR-col and/or ICU-MDR-inf.

RESULTS

750 patients (65.9% males, median age 65 years) were included, among whom 264 (35.2%) were immunocompromised. Reasons for ICU admission, severity scores and exposure to invasive devices and antibiotics during ICU stay were comparable between groups. After adjustment for center and pre-specified baseline confounders, immunocompromised patients had a lower incidence rate of ICU-MDR-col and/or ICU-MDR-inf (adjusted incidence ratio 0.68, 95% CI 0.52-0.91). When considered separately, the difference was significant for ICU-MDR-col, but not for ICU-MDR-inf. The distribution of MDR bacteria was comparable between groups, with a majority of Enterobacteriacae resistant to third-generation cephalosporins (~ 74%).

CONCLUSION

Immunocompromised patients had a significantly lower incidence rate of a composite outcome including ICU-MDR-col and/or ICU-MDR-inf. This finding points to the role of contact precautions and isolation measures, and could have important implications on antibiotic stewardship in this population.