2013 WSES guidelines for management of intra-abdominal infections

Intra-abdominal sepsis--epidemiology, aetiology and management

Peritonitis is a progressive disease leading inexorably from local peritoneal irritation to overwhelming sepsis and death unless this trajectory is interrupted by timely and effective therapy. In children peritonitis is usually secondary to intraperitoneal disease, the nature of which varies around the world. In rich countries, appendicitis is the principal cause whilst in poor countries diseases such as typhoid must be considered in the differential diagnosis. Where resources are limited, the clinical diagnosis of peritonitis mandates laparotomy for diagnosis and source control. In regions with unlimited resources, radiological investigation, ultrasound, CT scan or MRI may be used to select patients for non-operative management. For patients with appendicitis, laparoscopic surgery has achieved results comparable to open operation; however, in many centres open operation remains the standard. In complicated peritonitis "damage control surgery" may be appropriate wherein source control is undertaken as an emergency with definitive repair or reconstruction awaiting improvement in the patient's general condition. Awareness of abdominal compartment syndrome is essential. Primary peritonitis in rich countries is seen in high-risk groups, such as steroid-dependent nephrotic syndrome patients, whilst in poor countries the at-risk population is less well defined and the diagnosis is often made at surgery.

Pictorial review of normal postoperative cross-sectional imaging findings and infectious complications following laparoscopic appendectomy

Laparoscopic appendectomy is increasingly accepted as the preferred surgical treatment for acute appendicitis and represents one of the most common emergency operations performed in both adult and paediatric populations. However, in patients with perforated appendicitis laparoscopy is associated with an increased incidence of postoperative intraabdominal infections compared to open appendectomy. Nowadays urgent imaging is commonly requested by surgeons when postoperative complications are suspected. Due to the widespread use of laparoscopy, in hospitals with active surgical practices clinicians and radiologists are increasingly faced with suspected postappendectomy complications. This pictorial essay illustrates the normal cross-sectional imaging findings observed shortly after laparoscopic appendectomy and the spectrum of appearances of iatrogenic intraabdominal infections observed in adults and adolescents, aiming to provide radiologists with an increased familiarity with early postoperative imaging. Emphasis is placed on the role of multidetector CT, which according to the most recent World Society of Emergency Surgery (WSES) guidelines is the preferred and most accurate modality to promptly investigate suspected intraabdominal infections and highly helpful for correct therapeutic choice, particularly to identify those occurrences that require in-hospital treatment, drainage or surgical reintervention. In teenagers and young adults MRI represents an attractive alternative modality to detect or exclude iatrogenic abscesses without ionising radiation.

Teaching points

• Laparoscopic appendectomy is the preferred surgical treatment for uncomplicated acute appendicitis

• In perforated appendicitis laparoscopy results in increased incidence of intraabdominal infections

• Multidetector CT promptly assesses suspected iatrogenic intraabdominal infections

• Interpretation of early postoperative CT requires knowledge of normal postsurgical imaging findings

• Postsurgical infections include right-sided peritonitis, intraabdominal, pelvic or liver abscesses

Acute cholecystitis: WSES position statement

Background

The management of acute calculous cholecystitis still offers room for debate in terms of diagnosis, severity scores, treatment options and timing for surgery.

Material and methods

A systematic review about the treatment of acute cholecystitis has been completed. The recommendations of recent guidelines have also been examined taking into account the results of the review.

Results

The evidence available in the literature supports the recommendation about laparoscopic cholecystectomy as treatment of choice for acute cholecystitis. Surgery should be performed as soon as possible after the diagnosis because early treatment reduces total hospital stay and does not increase complication or conversion rates. The antibiotics can play different roles and attention should be posed to the risk of emerging resistance. A surgical or percutaneous drainage of the gallbladder is advocated by some authors in the advanced forms of inflammation or patients with severe co-morbidities; however, the available evidence does not support it, and further studies are necessary to clarify its role.

Impact of high prevalence of pseudomonas and polymicrobial gram-negative infections in major sub-/total traumatic amputations on empiric antimicrobial therapy: a retrospective study

Introduction

Emergency treatment of major sub-/total traumatic amputations continue to represent a clinical challenge due to high infection rates and serious handicaps. Effective treatment is based on two columns: surgery and antimicrobial therapy. Detailed identification of pathogen spectrum and epidemiology associated with these injuries is of tremendous importance as it guides the initial empiric antibiotic regimen and prevents adverse septic effents.

Methods

In this retrospective study 51 patients with major traumatic amputations (n = 16) and subtotal amputations (n = 35) treated from 2001 to 2010 in our trauma center were investigated. All patients received emergency surgery, debridement with microbiological testing within 6 h after admission and empircic antimicrobial therapy. Additionally to baseline patient characteristics, the incidence of positive standardized microbiologic testing combined with clinical signs of infection, pathogen spectrum, administered antimicrobial agents and clinical complications were analyzed.

Results

70.6% of the patients (n = 36) acquired wound infection. In 39% wounds were contaminated on day 1, whereas the mean length of duration until first pathogen detection was 9.1 ± 13.4 days after injury. In 37% polymicrobial colonization and 28% Pseudomonas were responsible for wound infections during hospitalization. In 45% the empirc antimicrobial therapy focussed on Gram positive strains did not cover the detected bacteria, according antimicrobial resistogram. It was significantly more often found in infections associated with Pseudomonas (p 0.02) or polymicrobial wound infections.

Conclusions

This epidemiologic study reveals a pathogen shift from Gram-positive to Gram-negative strains with high incidence of Pseudomonas and polymicrobial infections in sub-/total major traumatic amputations. Therefore, empiric antimicrobial treatment historically focussing on Gram-positive strains must be adjusted. We recommend the use of Piperacillin/Tazobactam for these injuries. As soon as possible antimicrobial treatment should be changed from empiric to goal directed therapy according to the microbiological tests and resistogram results.

The HAC trial (harmonic for acute cholecystitis): a randomized, double-blind, controlled trial comparing the use of harmonic scalpel to monopolar diathermy for laparoscopic cholecystectomy in cases of acute cholecystitis

BACKGROUND

The HARMONIC SCALPEL (H) is an advanced ultrasonic cutting and coagulating surgical device with important clinical advantages, such as: reduced ligature demand; greater precision due to minimal lateral thermal tissue damage; minimal smoke production; absence of electric corrents running through the patient. However, there are no prospective RCTs demonstrating the advantages of H compared to the conventional monopolar diathermy (MD) during laparoscopic cholecystectomy (LC) in cases of acute cholecystitis (AC).

METHODS

This study was a prospective, single-center, randomized trial (Trial Registration Number: NCT00746850) designed to investigate whether the use of H can reduce the incidence of intra-operative conversion during LC in cases of AC, compared to the use of MD. Patients were divided into two groups: both groups underwent early LC, within 72 hours of diagnosis, using H and MD respectively (H = experimental/study group, MD = control group). The study was designed and conducted in accordance with the regulations of Good Clinical Practice.

RESULTS

42 patients were randomly assigned the use of H (21 patients) or MD (21 patients) during LC. The two groups were comparable in terms of basic patient characteristics. Mean operating time in the H group was 101.3 minutes compared to 106.4 minutes in the control group (p=ns); overall blood loss was significantly lower in the H group. Conversion rate was 4.7% for the H group, which was significantly lower than the 33% conversion rate for the control group (p<0.05). Post-operative morbidity rates differed slightly: 19% and 23% in the H and control groups, respectively (p=ns). Average post-operative hospitalization lasted 5.2 days in the H group compared to 5.4 days in the control group (p=ns).

CONCLUSIONS

The use of H appears to correlate with reduced rates of laparoscopic-open conversion. Given this evidence, H may be more suitable than MD for technically demanding cases of AC.

Intra-abdominal Infections

Intra-abdominal infections are multifactorial, but all require prompt identification, diagnosis, and treatment. Resuscitation, early antibiotic administration, and source control are crucial. Antibiotic administration should initially be broad spectrum and target the most likely pathogens. When cultures are available, antibiotics should be narrowed and limited in duration. The method of source control depends on the anatomic site, site accessibility, and the patient's clinical condition. Patient-specific factors (advanced age and chronic medical conditions) as well as disease-specific factors (health care-associated infections and inability to obtain source control) combine to affect patient morbidity and mortality.

Antibiotic management of complicated intra-abdominal infections in adults: The Asian perspective

Regional epidemiological data and resistance profiles are essential for selecting appropriate antibiotic therapy for intra-abdominal infections (IAIs). However, such information may not be readily available in many areas of Asia and current international guidelines on antibiotic therapy for IAIs are for Western countries, with the most recent guidance for the Asian region dating from 2007. Therefore, the Asian Consensus Taskforce on Complicated Intra-Abdominal Infections (ACT-cIAI) was convened to develop updated recommendations for antibiotic management of complicated IAIs (cIAIs) in Asia. This review article is based on a thorough literature review of Asian and international publications related to clinical management, epidemiology, microbiology, and bacterial resistance patterns in cIAIs, combined with the expert consensus of the Taskforce members. The microbiological profiles of IAIs in the Asian region are outlined and compared with Western data, and the latest available data on antimicrobial resistance in key pathogens causing IAIs in Asia is presented. From this information, antimicrobial therapies suitable for treating cIAIs in patients in Asian settings are proposed in the hope that guidance relevant to Asian practices will prove beneficial to local physicians managing IAIs.

Cost of care and antibiotic prescribing attitudes for community-acquired complicated intra-abdominal infections in Italy: a retrospective study

INTRODUCTION

Complicated intra-abdominal infections (cIAIs) are a common cause of morbidity worldwide, and in spite of improvements in patient care, therapeutic failure still occurs, impacting in-hospital resource consumption. This study aimed to assess the costs associated with the treatment of community-acquired cIAIs, from the Italian National Health Service perspective.

METHODS

This retrospective study analyzed the charts of patients who were discharged from four Italian university hospitals between January 1 and December 31, 2009 with a primary diagnosis of community-acquired cIAIs. Patient characteristics, diagnosis, surgical procedure, antibiotic therapy, and length of hospital stay were all recorded and the cost of total hospital care was estimated. Costs were calculated in Euros at 2009 values.

RESULTS

The records of 260 patients (mean age 48.9 years; 57% males) were analyzed. The average cost of care for a patient hospitalized due to cIAI was €4385 (95% CI 3650-5120), with an average daily cost of €419 (95% CI 378-440). Antibiotic therapy represented just under half (44.3%) of hospitalization costs. The strongest predictor of the increase in hospital costs was clinical failure: patients who clinically failed received an average of 8.2 additional days of antibiotic therapy and spent 11 more days in hospital compared with patients who responded to first-line therapy (both p < 0.05 vs. patients who were successfully treated). Furthermore, they incurred €5592 in additional hospitalization costs (2.88 times the cost associated with clinical success) with 53% (€2973) of the additional costs attributable to antibiotic therapy. Overall, antibiotic appropriateness rate was 78.8% (n = 205), and was significantly higher in patients receiving combination therapy compared with those treated with monotherapy (97.3% vs. 64.6%).

CONCLUSION

The results of this study suggest that hospitals need to be aware of the clinical and economic consequences of antibiotic therapy of cIAIs and to reduce overall resource use and costs by improving the rate of success with appropriate initial empiric therapy.

High burden of extended-spectrum β-lactamase-positive Escherichia coli in geriatric patients

Few studies have described how an expanding elderly population influences the burden of antimicrobial resistance in micro-organisms. This study aimed to investigate trends in age-stratified extended-spectrum β-lactamase (ESBL)-positive Escherichia coli metrics in relation to an ageing population. The antimicrobial resistance database of E. coli from a healthcare region in Hong Kong from 2003 to 2012 was retrospectively reviewed. Future trends in age-stratified ESBL metrics were predicted up to 2022. Susceptibility results of clinical E. coli isolates from patients aged 0–74 years (n = 17 853) and aged ≥75 years (n = 17 047) were analysed. For the period 2003–2012, 23.7 % of the hospital admissions were of patients aged ≥75 years. However, approximately half of the annual ESBL-positive E. coli isolates were recovered from patients aged ≥75 years, being 55.0 % (233/424) in 2003 and 56.0 % (639/1142) in 2012. During this period of time, the annual prevalence and cumulative incidence of ESBL-positive E. coli in patients aged ≥75 years were significantly higher than in patients aged 0–74 years. From 2012–2022, it is predicted that ESBL-positive E. coli prevalence among patients aged 0–74 years and ≥75 years would increase from 25.4 % to 50.2 % and from 30.8 % to 70.0 %, respectively. In 2022, the predicted ESBL-positive E. coli cumulative incidence would be 63.7 per 10 000 admissions and 178.7 per 10 000 admissions among patients aged 0–74 years and ≥75 years, respectively. In conclusion, a rapidly expanding elderly population would substantially add to the burden of ESBL.

Current concept of abdominal sepsis: WSES position paper

Although sepsis is a systemic process, the pathophysiological cascade of events may vary from region to region.

Abdominal sepsis represents the host’s systemic inflammatory response to bacterial peritonitis.

It is associated with significant morbidity and mortality rates, and is the second most common cause of sepsis-related mortality in the intensive care unit.

The review focuses on sepsis in the specific setting of severe peritonitis.

Position paper: management of perforated sigmoid diverticulitis

Over the last three decades, emergency surgery for perforated sigmoid diverticulitis has evolved dramatically but remains controversial. Diverticulitis is categorized as uncomplicated (amenable to outpatient treatment) versus complicated (requiring hospitalization). Patients with complicated diverticulitis undergo computerized tomography (CT) scanning and the CT findings are used categorize the severity of disease. Treatment of stage I (phlegmon with or without small abscess) and stage II (phlegmon with large abscess) diverticulitis (which includes bowel rest, intravenous antibiotics and percutaneous drainage (PCD) of the larger abscesses) has not changed much over last two decades. On the other hand, treatment of stage III (purulent peritonitis) and stage IV (feculent peritonitis) diverticulitis has evolved dramatically and remains morbid. In the 1980s a two stage procedure (1st - segmental sigmoid resection with end colostomy and 2nd - colostomy closure after three to six months) was standard of care for most general surgeons. However, it was recognized that half of these patients never had their colostomy reversed and that colostomy closure was a morbid procedure. As a result starting in the 1990s colorectal surgical specialists increasing performed a one stage primary resection anastomosis (PRA) and demonstrated similar outcomes to the two stage procedure. In the mid 2000s, the colorectal surgeons promoted this as standard of care. But unfortunately despite advances in perioperative care and their excellent surgical skills, PRA for stage III/IV diverticulitis continued to have a high mortality (10-15%). The survivors require prolonged hospital stays and often do not fully recover. Recent case series indicate that a substantial portion of the patients who previously were subjected to emergency sigmoid colectomy can be successfully treated with less invasive nonoperative management with salvage PCD and/or laparoscopic lavage and drainage. These patients experience a surprisingly lower mortality and more rapid recovery. They are also spared the need for a colostomy and do not appear to benefit from a delayed elective sigmoid colectomy. While we await the final results ongoing prospective randomized clinical trials testing these less invasive alternatives, we have proposed (based primarily on case series and our expert opinions) what we believe safe and rationale management strategy.

Surgical delay is a critical determinant of survival in perforated peptic ulcer

Background

Morbidity and mortality following perforated peptic ulcer (PPU) remain substantial. Surgical delay is a well established negative prognostic factor, but evidence derives from studies with a high risk of bias. The aim of the present nationwide cohort study was to evaluate the adjusted effect of hourly surgical delay on survival after PPU.

Methods

This was a cohort study including all Danish patients treated surgically for PPU between 1 February 2003 and 31 August 2009. Medically treated patients and those with a malignant ulcer were excluded. The associations between surgical delay and 30-day survival are presented as crude and adjusted relative risks (RRs) with 95 per cent confidence intervals (c.i.).

Results

A total of 2668 patients were included. Their median age was 70·9 (range 16·2–104·2) years and 55·4 per cent (1478 of 2668) were female. Some 67·5 per cent of the patients (1800 of 2668) had at least one of six co-morbid diseases and 45·6 per cent had an American Society of Anesthesiologists fitness grade of III or more. A total of 708 patients (26·5 per cent) died within 30 days of surgery. Every hour of delay from admission to surgery was associated with an adjusted 2·4 per cent decreased probability of survival compared with the previous hour (adjusted RR 1·024, 95 per cent c.i. 1·011 to 1·037).

Conclusion

Limiting surgical delay in patients with PPU seems of paramount importance.