251
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Xu Z, Cheng B, Fu S, Liu X, Xie G, Li Z, Ji Y, Fu Q, Xu Z, Fang X. Coagulative biomarkers on admission to the ICU predict acute kidney injury and mortality in patients with septic shock caused by intra-abdominal infection. Infect Drug Resist 2019; 12:2755-2764. [PMID: 31564926 PMCID: PMC6732509 DOI: 10.2147/idr.s218592] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/26/2019] [Indexed: 12/29/2022] Open
Abstract
Purpose Sepsis-associated coagulopathy (SAC) contributes to the development of multiple organ failure (MOF) and increasing mortality. The present study was conducted to investigate whether coagulative biomarkers on admission to the intensive care unit (ICU) can predict acute kidney injury (AKI) and mortality in patients with septic shock caused by intra-abdominal infection (IAI). Patients and methods An observational retrospective study was conducted in the surgical ICU. We studied patients who met the criteria of septic shock (Sepsis-3) caused by IAI between January 1, 2013, and December 31, 2016. By adjusting for baseline characteristics, multivariate regression analyses were employed to identify independent risk factors for predicting AKI and mortality. Results Of the 138 enrolled patients, 65 patients developed AKI. The patients who developed AKI exhibited a dramatically higher Sequential Organ Failure Assessment (SOFA) score (median, 12), Acute Physiology and Chronic Health Evaluation (APACHE) II score (median, 27.5) and mortality rate. In both models, we found that activated partial thromboplastin time (APTT) (odds ratio (OR)=1.074, 95% confidence interval (CI) 1.030-1.120, p=0.001), prothrombin time (PT) (OR=1.162, 95% CI 1.037-1.302, p=0.010) and D-dimer level (OR=1.098, 95% CI 1.002-1.202, p=0.045) on admission to the ICU were significant risk factors for AKI. Moreover, Cox regression analysis showed that prolonged APTT (OR=1.065, 95% CI 1.025-1.107, p=0.001) was independently associated with high mortality. Conclusion In patients with septic shock caused by IAI, APTT, PT and D-dimer level on admission to the ICU were significantly associated with AKI. Furthermore, APTT was an independent predictor of 30-day mortality.
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Affiliation(s)
- Zhipeng Xu
- Department of Anesthesiology and Intensive Care Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Baoli Cheng
- Department of Anesthesiology and Intensive Care Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Shuiqiao Fu
- Department of Surgical Intensive Care Unit, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Xu Liu
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang City, Guizhou Province, People's Republic of China
| | - Guohao Xie
- Department of Anesthesiology and Intensive Care Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Zhongwang Li
- Department of Anesthesiology and Intensive Care Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Yun Ji
- Department of Surgical Intensive Care Unit, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Qinghui Fu
- Department of Surgical Intensive Care Unit, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Zhinan Xu
- Institute of Biological Engineering, College of Chemical and Biological Engineering, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Xiangming Fang
- Department of Anesthesiology and Intensive Care Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
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Núñez SA, Lacal V, Núñez J, Serruto G, Zárate MS, Verón MT. Antibiotic Resistance in Community-Acquired Intra-Abdominal Infections: Diabetes Mellitus as a Risk Factor. Surg Infect (Larchmt) 2019; 21:62-68. [PMID: 31441705 DOI: 10.1089/sur.2019.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Antimicrobial drug resistance in community-acquired (CA) infections is a growing problem. Knowing the local epidemiology is essential to design empirical antibiotic therapy. Therefore, we conducted this study to evaluate the resistance patterns of microorganisms isolated from surgical samples of community-acquired intra-abdominal infections (IAIs) and to determine the factors associated with resistance. Methods: We analyzed retrospectively the records of patients treated from January 2015 to June 2017 who had IAIs with positives aerobic cultures performed in the first 72 hours after admission. Surgical site infections, abdominal wall procedures, peritoneal dialysis catheters, and patients with admissions in the prior month were excluded. To identify the factors associated with resistance, we considered the resistance to the regimen recommended at our institution, ampicillin/sulbactam (AMS) plus ciprofloxacin (CIP). Results: There were 119 patients with 133 isolates, 59% women, and mean age 54 years. The main sources of infection were appendicitis (38%) and cholecystitis (20%), with 64 patients presenting a complicated IAI (cIAI), defined by the presence of peritonitis (55%). Resistance in Enterobacteriaceae was AMS 32% (6.4% intermediate resistance), CIP 31%, cefotaxime 9%, piperacillin/tazobactam (PTZ) 3%, trimethoprim/sulfamethoxazole 32%, gentamicin 9.5%, and amikacin 2%. Considering all patients, resistance to AMS + CIP was 16.8%. Factors associated with resistant to this regimen was, by univariable and multivariable analysis, the presence of diabetes mellitus (odds ratio [OR] 3.6; 95% confidence interval [CI] 1.1-11.6; p = 0.03). Female gender (OR 2.7; CI 0.9-8.4; p = 0.08) and complicated IAI (OR 2.0; CI 0.7-5.4; p = 0.17) were associated with resistance but did not reach statistical significance. Conclusion: High resistance to CIP and AMS was observed. Although the combination of AMS + CIP offers coverage for 84% of patients, PTZ should be considered as an option for patients with severe infections or diabetes mellitus. Finding factors associated with antibiotic resistance could help to select empirical therapy for CA IAIs better.
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Affiliation(s)
| | - Verónica Lacal
- Infectious Diseases Unit, Sanatorio Güemes, Buenos Aires, Argentina
| | - Jimena Núñez
- Infectious Diseases Unit, Sanatorio Güemes, Buenos Aires, Argentina
| | - Gisella Serruto
- Microbiology Laboratory, Sanatorio Güemes, Buenos Aires, Argentina
| | - Mariela S Zárate
- Microbiology Laboratory, Sanatorio Güemes, Buenos Aires, Argentina
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253
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Abstract
Background Data on common practice in the management of patients with complex appendicitis are scarce, especially for the adult population. Variation in the definition of complex appendicitis, indications for and the type of prolonged antibiotic prophylaxis have not been well studied yet. The aim of this study was to document current practice of the classification and postoperative management of complex appendicitis on an international level. Methods An online survey was dispersed among practicing surgeons and surgical residents. Survey questions pertained to the definition of a complex appendicitis, indications for antibiotic prophylaxis after appendectomy, the duration, route of administration and antibiotic agents used. Results A total of 137 survey responses were eligible for analysis. Most respondents were from Northern or Western Europe and were specialized in gastrointestinal surgery. Opinion varied substantially regarding the management of appendicitis, in particular for phlegmonous appendicitis with localized pus, gangrenous appendicitis and iatrogenic rupture of appendicitis. The most common duration of postoperative antibiotics was evenly spread over <3, 3, 5 and 7 days. Whereas most respondents indicated a combined intravenous and oral route of administration was common practice, 28% answered a completely intravenous route of administration was standard practice. Conclusion Current practice patterns in the classification and postoperative management of complex appendicitis are highly variable. Electronic supplementary material The online version of this article (10.1007/s00268-018-4806-4) contains supplementary material, which is available to authorized users.
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254
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Allaway MGR, Clement K, Eslick GD, Cox MR. Early Laparoscopic Washout may Resolve Persistent Intra-abdominal Infection Post-appendicectomy. World J Surg 2019; 43:998-1006. [PMID: 30478686 DOI: 10.1007/s00268-018-4871-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Intra-abdominal abscess (IAA) complicates 2-3% of patients having an appendicectomy. The usual management is prolonged antibiotics and drainage of the IAA. From 2006, our unit chose to use early re-laparoscopy and washout in patients with persistent sepsis following appendicectomy. The aims of this study were to assess the outcomes of early laparoscopic washout in patients with features of persistent intra-abdominal sepsis and compare those with percutaneous drainage and open drainage of post-appendicectomy IAA. METHODS A retrospective case note review was performed for all patients having a laparoscopic washout, percutaneous drainage or open drainage following appendicectomy between January 2006 and December 2017. RESULTS During the period, 4901 appendicectomies occurred. Forty-one (0.8%) patients had a laparoscopic washout, 16 (0.3%) had percutaneous drainage, and 6 (0.1%) had an open drainage. The demographics, ASA grade and pathology at initial appendicectomy were similar. The mean time after appendicectomy was significantly shorter for laparoscopic washout (4.1 days vs. 10.1 and 9.0 days, p = <0.003). The mean time for resolution of SIRS was significantly shorter (2.0 days vs. 3.3 and 5.2 days, p <0.02). The morbidity and length of stay were similar. CONCLUSION Early laparoscopic washout for persistent intra-abdominal sepsis may be an alternative to non-operative management and delayed intervention for IAA and may have better outcomes than either percutaneous drainage or open drainage. A prospective randomised comparison is required to further evaluate the indications and role of early laparoscopic washout post-appendicectomy.
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Affiliation(s)
- Matthew G R Allaway
- Department of Surgery, Nepean Hosptial, P. O. Box 67, Penrith, NSW, 2751, Australia
| | - Kristenne Clement
- Department of Surgery, Nepean Hosptial, P. O. Box 67, Penrith, NSW, 2751, Australia
| | - Guy D Eslick
- The Whiteley-Martin Research Centre, Clinical Sciences Building, Nepean Hospital, P. O. Box 67, Penrith, NSW, 2751, Australia
| | - Michael R Cox
- Department of Surgery, Nepean Hosptial, P. O. Box 67, Penrith, NSW, 2751, Australia. .,The Whiteley-Martin Research Centre, Clinical Sciences Building, Nepean Hospital, P. O. Box 67, Penrith, NSW, 2751, Australia.
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255
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Escolà-Vergé L, Pigrau C, Almirante B. Ceftolozane/tazobactam for the treatment of complicated intra-abdominal and urinary tract infections: current perspectives and place in therapy. Infect Drug Resist 2019; 12:1853-1867. [PMID: 31308706 PMCID: PMC6613001 DOI: 10.2147/idr.s180905] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/26/2019] [Indexed: 12/23/2022] Open
Abstract
The current prevalence of infections caused by multidrug-resistant (MDR) organisms is a global threat, and thus, the development of new antimicrobial agents with activity against these pathogens is a healthcare priority. Ceftolozane-tazobactam (C/T) is a new combination of a cephalosporin with a β-lactamase inhibitor that shows excellent in vitro activity against a broad spectrum of Enterobacteriaceae and Pseudomonas aeruginosa, including extended spectrum β-lactamase-producing (ESBL) strains and MDR or extensively drug-resistant (XDR) P. aeruginosa. In phase III randomized clinical trials, C/T demonstrated similar efficacy to meropenem for the treatment of complicated intra-abdominal infections (cIAIs) and superior efficacy to levofloxacin for the treatment of complicated urinary tract infections (cUTIs), including pyelonephritis. The drug is generally safe and well tolerated and its PK/PD profile is very favorable. Observational studies with C/T have revealed good efficacy for the treatment of different types of infection caused by MDR or XDR P. aeruginosa, including some that originated from the digestive or urinary tracts. The place of C/T in therapy is not well defined, but its use could be recommended in a carbapenem-sparing approach for the treatment of infections caused by ESBL-producing strains or for the treatment of infections caused by P. aeruginosa if there are no other more favorable therapeutic options. Further clinical experience is needed to position this new antimicrobial drug for the empirical treatment of cIAIs or cUTIs.
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Affiliation(s)
- Laura Escolà-Vergé
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Carlos Pigrau
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Benito Almirante
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
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256
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Vaos G, Dimopoulou A, Gkioka E, Zavras N. Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis. J Pediatr Surg 2019; 54:1365-1371. [PMID: 30115448 DOI: 10.1016/j.jpedsurg.2018.07.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/19/2018] [Accepted: 07/20/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE This study carried out a meta-analysis to compare immediate surgery (IS) with conservative treatment (CT) of complicated acute appendicitis (CAA) in children. METHODS Systematic literature research was performed for relevant studies published from 1969 to date. Trials of IS compared with CT were included. Outcomes of interest were postoperative morbidity and length of hospital stay (LOS). RESULTS Fifteen trials were studied (1.243 patients). CT achieved better rates of any complication type (odds ratio [OR] 0.22, [95% confidence interval (CI): 0.14, 0.38], p = 0.001) and wound infection (OR: 0.40 [95% CI: 0.17, 0.96], p = 0.041). Neither intraabdominal abscess (OR: 1.03 [95% CI: 0.31, 3.37], p = 0.958) nor postoperative ileus (OR: 0.29 [95% CI: 0.06, 1.44], p = 0.130) was affected by the treatment option. The polled difference in LOS showed a trend for shorter LOS in the IS group (standard mean difference [SMD]: 0.25 [95% CI: 0.07, -0.43], p = 0.007). CONCLUSIONS IS was associated with shorter LOS, while overall complication rates and wound infection declined significantly with CT. The development of intraabdominal abscess and postoperative ileus was not affected by the treatment of choice. The heterogeneity of most studies depicts the need for randomized controlled trials (RCTs) to discover safe management of CAA in children. LEVEL OF EVIDENCE III: Type of study: Meta-analysis.
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Affiliation(s)
- George Vaos
- Department of Paediatric Surgery, Attikon University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
| | - Anastasia Dimopoulou
- Department of Paediatric Surgery, Attikon University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Eleana Gkioka
- Second Department of Paediatrics, Athens Medical Center, Athens, Greece
| | - Nick Zavras
- Department of Paediatric Surgery, Attikon University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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257
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Petersen MW, Perner A, Jonsson AB, Bahador M, Sjövall F, Møller MH. Empirical metronidazole for patients with severe bacterial infection: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2019; 63:802-813. [PMID: 30729495 DOI: 10.1111/aas.13327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 12/28/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Metronidazole is the preferred empirical anti-anaerobic agent for patients with suspected anaerobic infection. The balance between benefits and harms of empirical metronidazole is unclear. We aimed to assess patient-important benefits and harms of empirical metronidazole vs placebo/no treatment in adult patients with severe bacterial infection of any origin. METHODS We conducted a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials assessing empirical metronidazole vs placebo/no treatment in adult hospitalized patients with severe bacterial infection. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, the Cochrane Handbook and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. A protocol and statistical analysis plan was published prior to conducting the review. RESULTS We included a total of nine trials (n = 1753 patients), all of which were adjudicated as having high risk of bias. We found no difference in the primary outcome mortality within 90 days (relative risk 1.56, 95% confidence interval 0.39-6.25). Fewer patients receiving metronidazole had secondary infections (relative risk 0.43, 95% CI: 0.27-0.68). Trial sequential analysis indicated high risk of random errors due to lack of data, and the quality of evidence was very low for all outcomes. CONCLUSIONS There is low quantity and quality of evidence supporting the use of empirical metronidazole in adult patients with severe bacterial infections of any origin, and no firm evidence for benefit or harm.
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Affiliation(s)
- Marie Warrer Petersen
- Department of Intensive Care 4131Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care 4131Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Andreas Bender Jonsson
- Department of Intensive Care 4131Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Marjan Bahador
- Department of Intensive Care 4131Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Fredrik Sjövall
- Department of Perioperative Medicine Skåne University Hospital Malmö Sweden
| | - Morten Hylander Møller
- Department of Intensive Care 4131Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
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258
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Huston JM, Kreiner L, Ho VP, Sanders JM, Duane TM. Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions. Surg Infect (Larchmt) 2019; 20:593-600. [PMID: 31188069 DOI: 10.1089/sur.2019.062] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Peptic ulcer disease (PUD) affects four million people worldwide. Perforated peptic ulcer (PPU) occurs in less than 15% of cases but is associated with significant morbidity and mortality rates. Administration of antibiotics is standard treatment for gastrointestinal perforations, including PPU. Although fungal growth is common in peritoneal fluid cultures from patients with PPU, current data suggest empiric anti-fungal therapy fails to improve outcomes. To examine the role of anti-fungal agents in the treatment of PPU, the Surgical Infection Society hosted an Update Symposium at its 37th Annual Meeting. Here, we provide a synopsis of the symposium's findings and a brief review of prospective and retrospective reports on the subject. Methods: A search of Pubmed/MEDLINE, EMBASE, and the Cochrane Library was performed between January 1, 2000, and November 1, 2018, comparing outcomes of PPU following empiric anti-fungal treatment versus no anti-fungal therapy. We used the search terms "perforated peptic ulcer," "gastroduodenal ulcer," "anti-fungal," and "perforated" or "perforation." Results: There are no randomized clinical trials comparing outcomes specifically for patients with PPU treated with or without empiric anti-fungal therapy. We identified one randomized multi-center trial evaluating outcomes for patients with intra-abdominal perforations, including PPU, that were treated with or without empiric anti-fungal therapy. We identified one single-center prospective series and three additional retrospective studies comparing outcomes for patients with PPU treated with or without empiric anti-fungal therapy. Conclusion: The current evidence reviewed here does not demonstrate efficacy of anti-fungal agents in improving outcomes in patients with PPU. As such, we caution against the routine use of empiric anti-fungal agents in these patients. Further studies should help identify specific subpopulations of patients who might derive benefit from anti-fungal therapy and help define appropriate treatment regimens and durations that minimize the risk of resistance, adverse events, and cost.
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Affiliation(s)
- Jared M Huston
- Departments of Surgery and Science Education, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Laura Kreiner
- Department of Surgery, Case Western Reserve University School of Medicine, The MetroHealth System, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, Case Western Reserve University School of Medicine, The MetroHealth System, Cleveland, Ohio
| | - James M Sanders
- Department of Pharmacy, John Peter Smith Health Network, Fort Worth, Texas
| | - Therese M Duane
- Department of Surgery, John Peter Smith Health Network, Fort Worth, Texas
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259
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Nguyen MP, Crotty MP, Daniel B, Dominguez E. An Evaluation of Guideline Concordance in the Management of Intra-Abdominal Infections. Surg Infect (Larchmt) 2019; 20:650-657. [PMID: 31464573 DOI: 10.1089/sur.2018.317] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Optimal treatment of intra-abdominal infections (IAIs) is multifaceted, typically requiring surgical intervention and antimicrobial therapy. Treatment of IAIs aligned with the 2017 revised Surgical Infection Society (SIS) guidelines may improve patient outcomes. Here we compare clinical outcomes of patients who received guideline concordant and discordant therapy for treatment of IAIs. Patients and Methods: This was a retrospective observational study of patients admitted from January 2013 to June 2016 with IAIs. Guideline concordant treatment was based on three criteria: source control, antibiotic choice, and antibiotic duration. The primary outcome was a composite of in-hospital mortality and 30-day re-admission. Multivariable logistic regression was used to determine independent factors associated with the composite end point. Results: A total of 221 patients were included, with guideline concordant treatment occurring in 117 (53%) patients. In-hospital mortality or 30-day re-admission occurred in 15 (12.8%) patients in the guideline concordant group compared with 24 (23.1%) in the guideline discordant group (p = 0.046). Empiric antibiotic choice was the most common component of discordance to guidelines (61% of patients). In multivariable analysis, guideline concordant treatment was associated with a decrease in the composite outcome (adjusted odds ratio [aOR] = 0.461, p = 0.045). In contrast, the presence of empiric methicillin-resistant Staphylococcus aureus (MRSA)/vancomycin-resistant Enterococcus (VRE) coverage (aOR: 2.645, p = 0.030), and moderate-to-severe liver disease (aOR: 8.081, p = 0.027) were associated with an increased risk for the composite outcome. Conclusions: Concordance to recommendations from the 2017 revised SIS guidelines is of critical importance in the optimal management of IAIs and further investigation of interventions to improve concordance are warranted.
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Affiliation(s)
- M Paul Nguyen
- Department of Pharmacy, Methodist Dallas Medical Center, Dallas, Texas
| | - Matthew P Crotty
- Department of Pharmacy, Methodist Dallas Medical Center, Dallas, Texas
| | - Betina Daniel
- Department of Pharmacy, Methodist Dallas Medical Center, Dallas, Texas
| | - Ed Dominguez
- Organ Transplant Infectious Diseases, Methodist Transplant Specialists, Methodist Dallas Medical Center, Dallas, Texas
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260
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Usefulness of Gram stain examination of peritoneal fluid in postoperative peritonitis to guide empirical antibiotherapy. Eur J Trauma Emerg Surg 2019; 46:1335-1340. [PMID: 31143982 DOI: 10.1007/s00068-019-01161-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/22/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE In postoperative peritonitis, Gram stain examination (GSE) of peritoneal fluid has been proposed as a guide for the prescription of glycopeptides and antifungal therapy in empirical antibiotherapy. No data support this approach for Gram-positive cocci. We aimed to evaluate the performance of GSE in predicting the results of the culture of peritoneal fluid. METHODS In this retrospective single-center study, concordance between GSE and culture of peritoneal fluid was assessed for different types of microorganisms. Factors associated with concordance of the two tests were evaluated in the subpopulation of Gram-positive cocci peritonitis. RESULTS Among the 152 episodes, the GSE was negative in 57 cases. The negative predictive value and the positive predictive value were 41% and 87% for Gram-positive cocci (GPC), 31% and 86% for Gram-negative bacilli, and 78% and 94% for fungi. GSE is not a reliable guide for the choice of empirical antibiotherapy and cannot reliably rule out the presence of GPC at culture. If we aim to achieve a high rate of adequacy, the systematic use of glycopeptide in the empirical antibiotherapy may be considered. CONCLUSION GSE shows poor performance to predict the results of culture of peritoneal fluid in postoperative peritonitis. Avoiding covering resistant GPC cannot be based on the result of GSE.
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261
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Cole K, Phlamon M, Petite SE. Comparison of Short-Course and Prolonged Antimicrobial Therapy in the Management of Intra-Abdominal Infections. Surg Infect (Larchmt) 2019; 20:519-523. [PMID: 31107174 DOI: 10.1089/sur.2019.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Guidelines recommend an antimicrobial therapy duration of four to seven days for intra-abdominal infections (IAIs). Despite evidence that shorter treatments are appropriate for this disease state, longer durations frequently are utilized in clinical practice. This study compared the clinical outcomes of short course (SC) and prolonged course (PC) antimicrobial therapy for IAI. Methods: This was a noninterventional, retrospective, single-center study. Adults admitted with documented IAI who received antimicrobial treatment for ≥48 hours were included. Results: A total of 175 patients were enrolled, 73 patients receiving SC (≤7 days) and 102 patients receiving PC (>7 days) therapy. No significant differences were observed in the primary outcome of clinical cure (74% versus 67.6%; p = 0.367). Secondary outcomes including hospital length of stay (LOS) (5.5 versus 5.8 days; p = 0.372), intensive care unit (ICU) LOS (3 versus 5 days; p = 0.117), 28-day all-cause mortality rate (4.1% versus 2%; p = 0.651), and 30-day re-admission rate (19.2% versus 20.6%; p = 0.818) also were not significantly different. Conclusions: There was no significant difference in the rate of clinical cure between SC and PC antimicrobial therapy. These results further support guideline recommendations for a shorter duration of antimicrobial therapy in IAI.
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Affiliation(s)
- Kelli Cole
- 1University of Toledo Medical Center, Toledo, Ohio
| | - Mina Phlamon
- 1University of Toledo Medical Center, Toledo, Ohio
| | - Sarah E Petite
- 2College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, Ohio
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262
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van de Groep K, Verhoeff TL, Verboom DM, Bos LD, Schultz MJ, Bonten MJM, Cremer OL. Epidemiology and outcomes of source control procedures in critically ill patients with intra-abdominal infection. J Crit Care 2019; 52:258-264. [PMID: 31054787 DOI: 10.1016/j.jcrc.2019.02.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/31/2018] [Accepted: 02/28/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To describe the characteristics and procedural outcomes of source control interventions among Intensive Care Unit (ICU) patients with severe intra-abdominal-infection (IAI). MATERIAL AND METHODS We identified consecutive patients with suspected IAI in whom a source control intervention had been performed in two tertiary ICUs in the Netherlands, and performed retrospective in-depth case reviews to evaluate procedure type, diagnostic yield, and adequacy of source control after 14 days. RESULTS A total of 785 procedures were observed among 353 patients, with initial interventions involving 266 (75%) surgical versus 87 (25%) percutaneous approaches. Surgical index procedures typically involved IAI of (presumed) gastrointestinal origin (72%), whereas percutaneous index procedures were mostly performed for infections of the biliary tract/pancreas (50%) or peritoneal cavity (33%). Overall, 178 (50%) patients required multiple interventions (median 3 (IQR 2-4)). In a subgroup of 236 patients having their first procedure upon ICU admission, effective source control was ultimately achieved for 159 (67%) subjects. Persistence of organ failure was associated with inadequacy of source control at day 14, whereas trends in inflammatory markers were non-predictive. CONCLUSIONS Approximately half of ICU patients with IAI require more than one intervention, yet successful source control is eventually achieved in a majority of cases.
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Affiliation(s)
- Kirsten van de Groep
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - Tessa L Verhoeff
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Diana M Verboom
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Lieuwe D Bos
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Marc J M Bonten
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
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263
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Montravers P, Martin-Loeches I. Source control and intra-abdominal infections: Still many questions and only limited answers. J Crit Care 2019; 52:265-266. [PMID: 31047742 DOI: 10.1016/j.jcrc.2019.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Philippe Montravers
- Département d'Anesthésie-Réanimation, CHU Bichat-Claude Bernard, HUPNVS, APHP, Paris, France; Université Paris Diderot - Sorbonne Paris Cité, Paris, France; INSERM UMR 1152 - Sorbonne Paris Cité, Paris, France.
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO). St James's Hospital, Dublin, Ireland; Hospital Clinic. CIBERes. Universidad de Barcelona, Barcelona, Spain
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264
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Talan DA, Saltzman DJ, DeUgarte DA, Moran GJ. Methods of conservative antibiotic treatment of acute uncomplicated appendicitis: A systematic review. J Trauma Acute Care Surg 2019; 86:722-736. [PMID: 30516592 PMCID: PMC6437084 DOI: 10.1097/ta.0000000000002137] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/09/2018] [Accepted: 10/29/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Meta-analyses and a recent guideline acknowledge that conservative management of uncomplicated appendicitis with antibiotics can be successful for patients who wish to avoid surgery. However, guidance as to specific management does not exist. METHODS PUBMED and EMBASE search of trials describing methods of conservative treatment was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS Thirty-four studies involving 2,944 antibiotic-treated participants were identified. The greatest experience with conservative treatment is in persons 5 to 50 years of age. In most trials, imaging was used to confirm localized appendicitis without evidence of abscess, phlegmon, or tumor. Antibiotics regimens were generally consistent with intra-abdominal infection treatment guidelines and used for a total of 7 to 10 days. Approaches ranged from 3-day hospitalization on parenteral agents to same-day hospital or ED discharge of stable patients with outpatient oral antibiotics. Minimum time allowed before response was evaluated varied from 8 to 72 hours. Although pain was a common criterion for nonresponse and appendectomy, analgesic regimens were poorly described. Trials differed in use of other response indicators, that is, white blood cell count, C-reactive protein, and reimaging. Diet ranged from restriction for 48 hours to as tolerated. Initial response rates were generally greater than 90% and most participants improved by 24 to 48 hours, with no related severe sepsis or deaths. In most studies, appendectomy was recommended for recurrence; however, in several, patients had antibiotic retreatment with success. CONCLUSION While further investigation of conservative treatment is ongoing, patients considering this approach should be advised and managed according to study methods and related guidelines to promote informed shared decision-making and optimize their chance of similar outcomes as described in published trials. Future studies that address biases associated with enrollment and response evaluation, employ best-practice pain control and antibiotic selection, better define cancer risk, and explore longer time thresholds for response, minimized diet restriction and hospital stays, and antibiotic re-treatment will further our understanding of the potential effectiveness of conservative management. LEVEL OF EVIDENCE Systematic review, level II.
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Affiliation(s)
- David A Talan
- From the Department of Emergency Medicine (D.A.T., G.J.M.); Division of Infectious Diseases (D.A.T., G.J.M.), Department of Medicine; Department of Surgery (D.J.S.), Olive View-UCLA Medical Center, Sylmar; and Department of Surgery (D.A.D.), Division of Pediatric Surgery, Harbor-UCLA Medical Center, Torrance, California
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265
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Posillico SE, Young BT, Ladhani HA, Zosa BM, Claridge JA. Current Evaluation of Antibiotic Usage in Complicated Intra-Abdominal Infection after the STOP IT Trial: Did We STOP IT? Surg Infect (Larchmt) 2019; 20:184-191. [PMID: 30676237 DOI: 10.1089/sur.2018.121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Sarah E. Posillico
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brian T. Young
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Husayn A. Ladhani
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brenda M. Zosa
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jeffrey A. Claridge
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
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266
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Haddad N, Kanj SS, Awad LS, Abdallah DI, Moghnieh RA. The 2018 Lebanese Society of Infectious Diseases and Clinical Microbiology Guidelines for the use of antimicrobial therapy in complicated intra-abdominal infections in the era of antimicrobial resistance. BMC Infect Dis 2019; 19:293. [PMID: 30925909 PMCID: PMC6441166 DOI: 10.1186/s12879-019-3829-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 02/15/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The Lebanese Society of Infectious Diseases and Clinical Microbiology (LSIDCM) is involved in antimicrobial stewardship. In an attempt at guiding clinicians across Lebanon in regards to the proper use of antimicrobial agents, members of this society are in the process of preparing national guidelines for common infectious diseases, among which are the guidelines for empiric and targeted antimicrobial therapy of complicated intra-abdominal infections (cIAI). The aims of these guidelines are optimizing patient care based on evidence-based literature and local antimicrobial susceptibility data, together with limiting the inappropriate use of antimicrobials thus decreasing the emergence of antimicrobial resistance (AMR) and curtailing on other adverse outcomes. METHODS Recommendations in these guidelines are adapted from other international guidelines but modeled based on locally derived susceptibility data and on the availability of pharmaceutical and other resources. RESULTS These guidelines propose antimicrobial therapy of cIAI in adults based on risk factors, site of acquisition of infection, and clinical severity of illness. We recommend using antibiotic therapy targeting third-generation cephalosporin (3GC)-resistant gram negative organisms, with carbapenem sparing as much as possible, for community-acquired infections when the following risk factors exist: prior (within 90 days) exposure to antibiotics, immunocompromised state, recent history of hospitalization or of surgery and invasive procedure all within the preceding 90 days. We also recommend antimicrobial de-escalation strategy after culture results. Prompt and adequate antimicrobial therapy for cIAI reduces morbidity and mortality; however, the duration of therapy should be limited to no more than 4 days when adequate source control is achieved and the patient is clinically stable. The management of acute pancreatitis is conservative, with a role for antibiotic therapy only in specific situations and after microbiological diagnosis. The use of broad-spectrum antimicrobial agents including systemic antifungals and newly approved antibiotics is preferably restricted to infectious diseases specialists. CONCLUSION These guidelines represent a major step towards initiating a Lebanese national antimicrobial stewardship program. The LSIDCM emphasizes on development of a national AMR surveillance network, in addition to a national antibiogram for cIAI stratified based on the setting (community, hospital, unit-based) that should be frequently updated.
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Affiliation(s)
- Nicholas Haddad
- Internal Medicine-Infectious Disease, Central Michigan University, Saginaw, MI 48602 USA
| | - Souha S. Kanj
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Lyn S. Awad
- Pharmacy Department, Makassed General Hospital, Beirut, Lebanon
| | | | - Rima A. Moghnieh
- Division of Infectious Diseases, Department of Internal Medicine, Makassed General Hospital, Beirut, Lebanon
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267
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de Wijkerslooth EML, van den Boom AL, Wijnhoven BPL. Disease burden of appendectomy for appendicitis: a population-based cohort study. Surg Endosc 2019; 34:116-125. [PMID: 30919056 PMCID: PMC6946751 DOI: 10.1007/s00464-019-06738-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/06/2019] [Indexed: 01/07/2023]
Abstract
Background Few large-scale epidemiologic studies evaluate the clinical and economic burden of appendicitis. These data may impact future research and treatment strategies. In this study, the objective was to determine the burden of appendectomy for appendicitis in terms of incidence rates, length of hospital stay (LOS) and hospital costs on a national level. In addition, outcomes were compared for subgroups based on surgical treatment, age and hospital setting. Methods Observational retrospective population-based cohort study using the national Dutch healthcare reimbursement registry, which covers hospital registration and reimbursement for 17 million inhabitants. Patients with a diagnosis of appendicitis who underwent appendectomy between 2006 and 2016 were included. Primary outcomes were incidence rates, LOS and hospital costs. Results A total of 135,025 patients were included. Some 53% of patients was male, and 64% was treated in a general hospital. The overall incidence rate of appendectomy was 81 per 100,000 inhabitants and showed a significant decreasing trend across time and age. Mean ± SD LOS per patient was 3.66 ± 3.5 days. LOS showed a significant increase with age and was significantly longer for open versus minimally invasive appendectomy. Mean ± SD hospital costs per patient were €3700 ± 1284. Costs were initially lower for open compared to minimally invasive appendectomy, but were similar from 2012 onward. Compared to non-university hospitals, patients treated in university hospitals had a significantly longer LOS and higher costs. Conclusions Appendectomy for appendicitis represents a substantial clinical and economic burden in the Netherlands. A preference for minimally invasive technique seems justified.
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Affiliation(s)
| | - Anne Loes van den Boom
- Department of Surgery, Erasmus MC - University Medical Center, PO Box 2040, 3000CA, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Center, PO Box 2040, 3000CA, Rotterdam, The Netherlands
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268
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Tsuchiya A, Yasunaga H, Tsutsumi Y, Kawahara T, Matsui H, Fushimi K. Nationwide observational study of mortality from complicated intra-abdominal infections and the role of bacterial cultures. Br J Surg 2019; 106:606-615. [PMID: 30883708 DOI: 10.1002/bjs.11095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/30/2018] [Accepted: 11/26/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The benefit of taking intra-abdominal cultures during source control procedures in patients with complicated intra-abdominal infection (CIAI) is unknown. The aim of this study was to evaluate whether intra-abdominal cultures reduce the mortality rate of CIAI. METHODS The Japanese Diagnosis Procedure Combination database was used to identify adult patients with CIAI who had undergone source control procedures on the first day of admission to hospital between April 2014 and March 2016. In-hospital mortality was compared between patients who did and those who did not have intra-abdominal cultures taken. A generalized linear mixed-effect logistic regression model and a random intercept per hospital were used to adjust for baseline confounders and institutional differences. Subgroup analyses were also performed according to disease cause, site of onset and severity of CIAI. RESULTS Intra-abdominal cultures were taken from 16 303 of 41 495 included patients. Multivariable logistic regression analysis showed that patients with intra-abdominal cultures had a significantly lower mortality than those without (odds ratio 0·85, 95 per cent c.i. 0·77 to 0·95). Subgroup analyses revealed statistically significant differences in mortality between patients with and without cultures among those with lower intestinal perforation, biliary tract infection/perforation, healthcare-associated CIAI and high-risk community-acquired CIAI. CONCLUSIONS Intra-abdominal cultures obtained during source control procedures may reduce in-hospital mortality, especially in patients with lower intestinal perforation, biliary tract infection/perforation, or healthcare-associated or high-risk community-acquired CIAI.
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Affiliation(s)
- A Tsuchiya
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Centre, Ibaraki, Japan
| | - H Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Y Tsutsumi
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Centre, Ibaraki, Japan
| | - T Kawahara
- Biostatistics Division, Central Coordinating Unit, Clinical Research Support Centre, University of Tokyo Hospital, Tokyo, Japan
| | - H Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - K Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
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269
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Hamdy RF, Handy LK, Spyridakis E, Dona D, Bryan M, Collins JL, Gerber JS. Comparative Effectiveness of Ceftriaxone plus Metronidazole versus Anti-Pseudomonal Antibiotics for Perforated Appendicitis in Children. Surg Infect (Larchmt) 2019; 20:399-405. [PMID: 30874482 DOI: 10.1089/sur.2018.234] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Appendicitis is the most common pediatric surgical emergency and one of the most common indications for antibiotic use in hospitalized children. The antibiotic choice differs widely across children's hospitals, and the optimal regimen for perforated appendicitis remains unclear. Methods: We conducted a retrospective cohort study comparing initial antibiotic regimens for perforated appendicitis at a large tertiary-care children's hospital. Children hospitalized between January 2011 and March 2015 who underwent surgery for perforated appendicitis were identified by ICD-9 codes with confirmation by chart review. Patients were excluded if they had been admitted ≥48 hours prior to diagnosis, had a history of appendicitis, received inotropic agents, were immunocompromised, or were given an antibiotic regimen other than ceftriaxone plus metronidazole (CTX/MTZ) or an anti-pseudomonal drug (cefepime, piperacillin/tazobactam, ciprofloxacin, imipenem, or meropenem) within the first two days after diagnosis. The primary outcome of interest was post-operative complications, defined as development of an incisional infection or abscess within six weeks of hospital discharge. Results: Of the 353 children who met the inclusion criteria, 252 (71%) received CTX/MTZ and the others received an anti-pseudomonal regimen. A post-operative complication occurred in 37 (14.7%) of the CTX/MTZ group versus 18 (17.8%) of the anti-pseudomonal group. Antibiotic-related complications occurred in 4.4% of children on CTX/MTZ and 6.9% of children on anti-pseudomonal antibiotics (p = 0.32). In a multivariable logistic regression model adjusting for sex, age, ethnicity, and duration of symptoms prior to presentation, the adjusted odds ratio for post-operative complications in children receiving anti-pseudomonal antibiotics was 1.25 (95% confidence interval 0.66-2.40). Conclusion: Post-operative complication rates did not differ for children treated with CTX/MTZ versus a broader-spectrum regimen.
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Affiliation(s)
- Rana F Hamdy
- 1 Department of Pediatrics, Children's National Health System, Washington, DC
| | - Lori K Handy
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Evangelos Spyridakis
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniele Dona
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew Bryan
- 3 Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia
| | - Joy L Collins
- 4 Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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270
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Catalase-Containing Silica Particles as Ultrasound-Based Hydrogen Peroxide Sensors to Determine Infected From Noninfected Fluid Collections in Humans. AJR Am J Roentgenol 2019; 213:W9-W16. [PMID: 30860893 DOI: 10.2214/ajr.18.20779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE. Hydrogen peroxide (H2O2) plays a key role in neutrophil oxidative defense against infection. Catalase-containing silica nanoshells are nanoparticles that generate O2 microbubbles imaged with ultrasound in the presence of elevated H2O2. We aimed to determine whether ultrasound-detectable O2 microbubbles produced by catalase-containing silica nanoshells can determine whether fluid collections drained from patients are infected. SUBJECTS AND METHODS. During this HIPAA-compliant, institutional review board-approved study, 52 human fluid samples were collected from clinically required image-guided percutaneous drainage procedures. Catalase-containing silica nanoshells were added to the fluid samples during imaging in real time using a Sequoia-512 15L8-S linear transducer (Siemens Healthcare). Production of detectable microbubbles was graded subjectively as negative (noninfected) or positive (infected) with low, moderate, or high confidence by a single observer blinded to all clinical data. The truth standard was microbiology laboratory culture results. Performance characteristics including ROC curves were calculated. RESULTS. Microbubble detection to distinguish infected from noninfected fluids was 84% sensitive and 72% specific and offered negative and positive predictive values of 89% and 64%, respectively. The AUC was 0.79. Six of nine false-positive samples were peritoneal fluid collections that were all collected from patients with decompensated cirrhosis. CONCLUSION. The presence of elevated H2O2 indicated by microbubble formation in the presence of catalase-containing silica nanoshells is sensitive in distinguishing infected from noninfected fluids and offers a relatively high negative predictive value. False-positive cases may result from noninfectious oxidative stress. Catalase-containing silica nanoshells may constitute a novel point-of-care test performed at time of percutaneous drainage, potentially obviating placement of drains into otherwise sterile collections and minimizing risk of secondary infection or other complication.
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271
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Mora-Guzmán I, Rubio-Perez I, Domingo-Garcia D, Martin-Perez E. Carbapenemase-producing Enterobacteriaceae infections in General Surgery patients: Our experience. Enferm Infecc Microbiol Clin 2019; 38:42-43. [PMID: 30837166 DOI: 10.1016/j.eimc.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Ismael Mora-Guzmán
- Department of General Surgery, Hospital Universitario La Princesa, Madrid, Spain.
| | - Ines Rubio-Perez
- Department of General Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Diego Domingo-Garcia
- Department of Clinical Microbiology, Hospital Universitario La Princesa, Madrid, Spain
| | - Elena Martin-Perez
- Department of General Surgery, Hospital Universitario La Princesa, Madrid, Spain
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272
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Liu Q, Wu J, Wang Z, Wu X, Wang G, Ren J. Polymicrobial Bacteremia Involving Klebsiella pneumoniae in Patients with Complicated Intra-Abdominal Infections: Frequency, Co-Pathogens, Risk Factors, and Clinical Outcomes. Surg Infect (Larchmt) 2019; 20:317-325. [PMID: 30735082 DOI: 10.1089/sur.2018.207] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Klebsiella pneumoniae has gained notoriety because of its high antibiotic resistance and mortality. We compared the clinical features and outcomes of polymicrobial bacteremia involving K. pneumoniae (PBKP). Patients and Methods: A retrospective observational study of patients with polymicrobial and monomicrobial bacteremia involving K. pneumoniae from January 2012 to December 2016 was performed. The expression of resistance and virulence genes of 27 strains was also compared by polymerase chain reaction (PCR). Results: Among the polymicrobial group, the most common accompanying micro-organism was Escherichia coli. No differences in the expression of resistance and virulence genes was found among the 27 strains collected from the group. The analysis of the outcomes revealed that the patients with PBKP were more likely to have recurrent blood stream infections (p = 0.038), longer intensive care unit (ICU) lengths of stay (p = 0.043), and a higher total hospitalization cost (p = 0.045). However, no substantial differences in mortality were found between the two groups. The multivariable analysis revealed that a longer hospital stay prior to the onset of bacteremia (>20 days) was an independent risk factor for PBKP (p = 0.034), and the Sequential Organ Failure Assessment (SOFA) score upon onset of infection (p = 0.013), the adequacy of source control (p < 0.001), and iron supplementation (p = 0.003) were identified as independent predictors of mortality in patients with KP bacteremia. Conclusions: The development of septic shock and the concomitant use of iron supplementation are associated with higher mortality in patients with KP bacteremia, and PBKP did not increase the mortality of these patients, possibly because of the ability of K. pneumoniae to obscure the effects of other bacteria. Thus, adequate source control is more important than high-dose antibiotic therapy and is linked to higher survival.
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Affiliation(s)
- Qinjie Liu
- 1 Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Jie Wu
- 1 Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Zhiwei Wang
- 2 Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, People's Republic of China
| | - Xiuwen Wu
- 1 Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Gefei Wang
- 1 Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Jianan Ren
- 1 Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China.,2 Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, People's Republic of China
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273
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Prospective evaluation of a clinical response directed pathway for complicated appendicitis. J Pediatr Surg 2019; 54:272-275. [PMID: 30528202 DOI: 10.1016/j.jpedsurg.2018.10.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/30/2018] [Indexed: 11/20/2022]
Abstract
AIM Despite evidence to suggest shorter durations of antibiotics are safe in complicated appendicitis, the practice has not been widely adopted in the UK. Our aim was to determine whether a clinical pathway that tailors antibiotics to clinical condition was safe and effective. METHODS A new post-operative pathway (NewPath) was devised that reduced mandatory intravenous antibiotics for complicated appendicitis (perforated or gangrenous) from 5 to 3 days post-operatively, provided the child was apyrexial for >12 h and tolerating oral diet. Oral antibiotics were only given if white-blood-cell counts were raised. Data were collected prospectively (NewPath) and compared to 100 cases immediately prior. Data are presented as median [IQR]. Comparisons used the Fisher's exact or Mann Whitney U tests as appropriate. Significance was defined as p < 0.05. RESULTS One hundred sixty-four children completed the NewPath over 11 months. Age and normal appendicectomy rate were similar [NewPath vs. control, 9y (6-12) vs. 10y (7-13) and 19/164 (12%) vs.15/100 (15%)]. Complicated appendicitis rates were 88/164 [54%] vs. 42/100 [42%]; p = 0.08. Length of stay was shorter for the NewPath [5 (4-7) vs. 7 (6-8) days; p = 0.009], and fewer required oral antibiotics [35/88 (40%) vs. 26/42 (62%); p = 0.01]. Readmissions within 28 days [24/88 (27%) vs. 8/42 (19%), p = 0.39) and intra-abdominal collections [20/88 (23%) vs. 6/42 (14%), p = 0.35] were similar. CONCLUSIONS Post-operative appendicitis care guided by clinical progress and white-blood-cell count can reduce hospital stay and antibiotic use without increasing complications. Pathways such as this could save considerable health resource and contribute to important antimicrobial stewardship initiatives. LEVEL OF EVIDENCE Level III.
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274
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Peeters P, Ryan K, Karve S, Potter D, Baelen E, Rojas-Farreras S, Rodríguez-Baño J. The impact of initial antibiotic treatment failure: real-world insights in patients with complicated, health care-associated intra-abdominal infection. Infect Drug Resist 2019; 12:329-343. [PMID: 30774399 PMCID: PMC6362915 DOI: 10.2147/idr.s184116] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose The RECOMMEND study (NCT02364284; D4280R00005) assessed the clinical management patterns and treatment outcomes associated with initial antibiotic therapy (IAT; antibiotics administered ≤48 hours post-initiation of antibiotic therapy) for health care-associated infections across five countries. Patients and methods Data were collected from a retrospective chart review of patients aged ≥18 years with health care-associated complicated intra-abdominal infection (cIAI). Potential risk factors for IAT failure were identified using logistic regression analyses. Results Of 385 patients with complete IAT data, bacterial pathogens were identified in 270 (70.1%), including Gram-negative isolates in 221 (81.9%) and Gram-positive isolates in 92 (34.1%). Multidrug-resistant (MDR) pathogens were identified in 112 patients (41.5% of patients with a pathogen identified). IAT failure rate was 68.3% and in-hospital mortality rate was 40.8%. Multivariate regression analysis demonstrated three factors to be significantly associated with IAT failure: patients admitted/transferred to the intensive care unit during index hospitalization, isolation of an MDR pathogen and previous treatment with β-lactam antibiotics. Conclusion We reveal the real-world insights into the high rates of IAT failure and mortality observed among patients with cIAI. These data highlight the challenges associated with choosing IAT, the impact of MDR pathogens on IAT outcomes and the importance of tailoring IAT selection to account for local epidemiology and patient history.
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Affiliation(s)
| | - Kellie Ryan
- Health Economics and Outcomes Research, AstraZeneca, Gaithersburg, MD, USA
| | - Sudeep Karve
- Health Economics and Outcomes Research, AstraZeneca, Gaithersburg, MD, USA
| | - Danielle Potter
- Medical Evidence and Observational Research Center, AstraZeneca, Gaithersburg, MD, USA
| | - Elisa Baelen
- Real-World Insights, IQVIA, St Prex, Switzerland
| | | | - Jesús Rodríguez-Baño
- Department of Medicine, Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena - Instituto de Biomedicina de Sevilla (IBiS), Universidad de Sevilla, Seville, Spain,
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275
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Rickard J. Treating Surgical Infections in Low- and Middle-Income Countries: Source Control, Then What? Surg Infect (Larchmt) 2019; 20:192-196. [PMID: 30698510 DOI: 10.1089/sur.2018.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Surgical infections present a significant burden of disease globally. Management focuses on source control and appropriate antibiotic therapy. This remains a challenge in low- and middle-income settings, where access to surgical care and antibiotics is limited. This paper discusses the complex challenges facing the management of surgical infections in low- and middle-income countries.
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Affiliation(s)
- Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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Timsit JF, Bassetti M, Cremer O, Daikos G, de Waele J, Kallil A, Kipnis E, Kollef M, Laupland K, Paiva JA, Rodríguez-Baño J, Ruppé É, Salluh J, Taccone FS, Weiss E, Barbier F. Rationalizing antimicrobial therapy in the ICU: a narrative review. Intensive Care Med 2019; 45:172-189. [PMID: 30659311 DOI: 10.1007/s00134-019-05520-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/04/2019] [Indexed: 12/13/2022]
Abstract
The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.
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Affiliation(s)
- Jean-François Timsit
- Medical and Infectious Diseases ICU, APHP, Bichat-Claude Bernard Hospital, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France.
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Olaf Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - George Daikos
- Scool of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andre Kallil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric Kipnis
- Surgical Critical Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Lille, Lille, France
| | - Marin Kollef
- Critical Care Research, Washington University School of Medicine and Respiratory Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Kevin Laupland
- Department of Medicine, Royal Inland Hospital, Kamloops, Canada
| | - Jose-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar São João and Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jesús Rodríguez-Baño
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena, Departament of Medicine, University of Sevilla, Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Étienne Ruppé
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
- Bacteriology Laboratory, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jorge Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, IDOR, Rio De Janeiro, Brazil
| | | | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, AP-HP, Clichy, France
- INSERM, CRI, UMR 1149, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
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277
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Fluoroquinolone-based versus β-lactam-based regimens for complicated intra-abdominal infections: a meta-analysis of randomised controlled trials. Int J Antimicrob Agents 2019; 53:746-754. [PMID: 30639629 DOI: 10.1016/j.ijantimicag.2019.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/27/2018] [Accepted: 01/06/2019] [Indexed: 11/24/2022]
Abstract
Complicated intra-abdominal infections (cIAIs) are common and confer significant morbidity, mortality and costs. In this era of evolving antimicrobial resistance, selection of appropriate empirical antimicrobials is paramount. This systematic review and meta-analysis of randomised controlled trials compared the effectiveness and safety of fluoroquinolone (FQ)-based versus β-lactam (BL)-based regimens for the treatment of patients with cIAIs. Primary outcomes were treatment success in the clinically evaluable (CE) population and all-cause mortality in the intention-to-treat (ITT) population. Subgroup analyses were performed based on specific antimicrobials, infection source and isolated pathogens. Seven trials (4125 patients) were included. FQ-based regimens included moxifloxacin (four studies) or ciprofloxacin/metronidazole (three studies); BL-based regimens were ceftriaxone/metronidazole (three studies), carbapenems (two studies) or piperacillin/tazobactam (two studies). There was no difference in effectiveness in the CE (2883 patients; RR = 1.00, 95% CI 0.95-1.04) or ITT populations (3055 patients; RR = 0.97, 95% CI 0.94-1.01). Mortality (3614 patients; RR = 1.04, 95% CI 0.75-1.43) and treatment-related adverse events (2801 patients; RR = 0.97, 95% CI 0.70-1.33) were also similar. On subset analysis, moxifloxacin was slightly less effective than BLs in the CE (1934 patients; RR = 0.96, 95% CI 0.93-0.99) and ITT populations (1743 patients; RR = 0.94, 95% CI 0.91-0.98). Although FQ- and BL-based regimens appear equally effective and safe for the treatment of cIAIs, limited data suggest slightly inferior results with moxifloxacin. Selection of empirical coverage should be based on local bacterial epidemiology and patterns of resistance as well as antimicrobial stewardship protocols.
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278
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Waele JJD. What every intensivist should know about the management of peritonitis in the intensive care unit. Rev Bras Ter Intensiva 2019; 30:9-14. [PMID: 29742214 PMCID: PMC5885225 DOI: 10.5935/0103-507x.20180007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/10/2017] [Indexed: 12/21/2022] Open
Affiliation(s)
- Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
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279
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Wang F, Ren J, Wang G, Ren H, Hong Z, Wu X. Early Active Drainage by Fine Tube Bundles Improves the Clinical Outcome of Anastomotic Leak after Abdominal Surgery: A Pilot Randomized, Controlled Trial in Two Tertiary Hospitals in China. Surg Infect (Larchmt) 2019; 20:208-214. [PMID: 30614767 DOI: 10.1089/sur.2018.177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Post-operative anastomotic leak (PAL) is the most feared complication after abdominal surgery. Timely drainage of enteric effluent is beneficial in the healing of PAL. METHODS We introduced a new and feasible approach for early active drainage of PAL using fine tube bundles (FTBs). The therapeutic effects of FTBs were observed prospectively and compared with the traditional drainage tube without FTBs in a non-blinded randomized controlled trial. RESULTS Sixty patients with PAL in two tertiary hospitals in China from 2010 to 2016 were included in this study. Of these patients, 30 received FTBs and 30 were treated with a traditional drainage tube. The implantation failure rate was zero in the FTB group. No statistical difference was observed between the two groups in terms of demographic data. After these interventions, patients in the FTB group showed a faster decline in infection-related indictors, a higher ratio of spontaneous PAL closure, and shorter treatment duration of antibacterial agents compared with those in the traditional drainage tube group. Fatal complications and financial cost were also reduced in the FTB group. CONCLUSION Fine tube bundles may contribute to the healing of PAL through active drainage. This method should be validated by further clinical trials for wider use.
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Affiliation(s)
- Feng Wang
- 1 Department of Surgery, Jinling Hospital, Nanjing, China.,2 Department of Surgery, Affiliated Hospital of Inner Mongolia Medical University, Inner Mongolia, China.,3 Department of Surgery, BeijingTsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Jianan Ren
- 1 Department of Surgery, Jinling Hospital, Nanjing, China
| | - Gefei Wang
- 1 Department of Surgery, Jinling Hospital, Nanjing, China
| | - Huajian Ren
- 1 Department of Surgery, Jinling Hospital, Nanjing, China
| | - Zhiwu Hong
- 1 Department of Surgery, Jinling Hospital, Nanjing, China
| | - Xiuwen Wu
- 1 Department of Surgery, Jinling Hospital, Nanjing, China
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280
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Maurice Lalisang T, Mazni Y, Jeo W, Marbun VG. Factor influencing outcome of source control in the management of complicated intra-abdominal infection in Cipto Mangunkusumo University Hospital. FORMOSAN JOURNAL OF SURGERY 2019. [DOI: 10.4103/fjs.fjs_122_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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281
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Xu X, Duan Z, Ding H, Li W, Jia J, Wei L, Linghu E, Zhuang H. Chinese guidelines on the management of ascites and its related complications in cirrhosis. Hepatol Int 2019; 13:1-21. [PMID: 30656520 DOI: 10.1007/s12072-018-09923-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/20/2018] [Indexed: 12/12/2022]
Abstract
The Chinese Society of Hepatology developed the current guidelines for the Management of Ascites and Its Related Complications in Cirrhosis based on the published evidences and the panelists' consensus. The guidelines provided recommendations for the diagnosis and management of cirrhotic ascites emphasizing a step-wise approach with the first-, second-, and third-line therapy. For refractory ascites, vasoconstrictors and albumin are recommended for splanchnic vasodilation and selective vasopressin (V2) receptor antagonists for moderate-to-severe hyponatremia. For spontaneous bacterial peritonitis, empirical anti-infection treatment was recommended based on the local microbiological examination of community- or hospital-acquired infections. For hepatorenal syndrome, the administration of vasopressor terlipressin and albumin is recommended.
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Affiliation(s)
- Xiaoyuan Xu
- Department of Infectious Diseases, Peking University First Hospital, Beijing, 100034, China.
| | - Zhongping Duan
- Artificial Liver Center, Beijing You-An Hospital, Capital Medical University, Beijing, 100069, China
| | - Huiguo Ding
- Center for Hepatology and Gastroenterology, Beijing You-An Hospital, Capital Medical University, Beijing, China
| | - Wengang Li
- Liver Tumor Diagnosis, Treatment and Research Center, 302 Military Hospital of China, Beijing, China
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lai Wei
- Institute of Hepatology, Peking University People's Hospital, Beijing, China
| | - Enqiang Linghu
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing, China
| | - Hui Zhuang
- Department of Pathogen Biology, Peking University Health Science Center, Beijing, China
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282
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Liu S, Wang M, Guan W. Vancomycin in the treatment of adult intra-abdominal infections: do we have strong evidences? Infect Drug Resist 2018; 11:2539-2543. [PMID: 30584342 PMCID: PMC6290861 DOI: 10.2147/idr.s185331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The management of intra-abdominal infections (IAIs) primarily includes adequate antimicrobial therapy and appropriate source control. Vancomycin is a fundamental and most effective antimicrobial agent. The aim of this study is to search and evaluate the quality of clinical evidences regarding the exclusive use of vancomycin for the management of adult IAIs. For this purpose, we first summarized the recommendations on exclusive use of vancomycin in adult IAIs from six leading guidelines and excavated the relevant supporting references. We subsequently conducted a literature search to screen eligible clinical studies in this field for possible systematic review. Our investigation demonstrates that the exclusive use of vancomycin is recommended in restricted indications, that is, IAIs caused by Enterococcus spp. or methicillin-resistant Staphylococcus aureus. However, the supporting references in the guidelines are more subjective instead of objective, which mainly originate from experts’ personal experiences or from the therapeutic efficacy of vancomycin in other types of infections rather than in IAIs. Furthermore, our literature search fails to find high-level evidence. In conclusion, current low-level evidences are inadequate to elicit strong recommendations on the exclusive use of vancomycin in the treatment of adult IAIs. Our study would be helpful for the rational use of vancomycin and deceleration of the emerging vancomycin resistance rates.
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Affiliation(s)
- Song Liu
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China, ;
| | - Meng Wang
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China, ;
| | - Wenxian Guan
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China, ;
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283
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Fabre V, Nemati K, Avdic E, Cosgrove SE, Amoah J, Tamma PD. The Role of Ertapenem for the Treatment of Complicated Intra-abdominal Infections With a Positive Culture for Enterococcus faecalis. Open Forum Infect Dis 2018; 6:ofy339. [PMID: 30648129 PMCID: PMC6329900 DOI: 10.1093/ofid/ofy339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/12/2018] [Indexed: 12/29/2022] Open
Abstract
Controversy remains as to whether Enterococcus faecalis recovered from intra-abdominal infections (IAIs) requires targeted therapy. In a multicenter study comparing patients with IAIs from which E. faecalis was identified in intra-abdominal cultures, no difference in clinical outcomes was observed between patients receiving ertapenem vs those receiving piperacillin/tazobactam.
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Affiliation(s)
- Valeria Fabre
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Koorosh Nemati
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edina Avdic
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sara E Cosgrove
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joe Amoah
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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284
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Chen Y, Zhu D, Zhang Y, Zhao Y, Chen G, Li P, Xu L, Yan P, Hickman MA, Xu X, Tawadrous M, Wible M. A multicenter, double-blind, randomized, comparison study of the efficacy and safety of tigecycline to imipenem/cilastatin to treat complicated intra-abdominal infections in hospitalized subjects in China. Ther Clin Risk Manag 2018; 14:2327-2339. [PMID: 30584308 PMCID: PMC6281154 DOI: 10.2147/tcrm.s171821] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the efficacy and safety of tigecycline in treating complicated intra-abdominal infections (cIAIs) in hospitalized patients in China. Patients and methods A Phase IV, multicenter, randomized, double-blinded, active-controlled, non-inferiority study was conducted. Hospitalized cIAI patients ≥18 years of age were randomized (1:1) to receive intravenous tigecycline (initial dose 100 mg, then 50 mg q12h) or imipenem/cilastatin (500 mg/500 mg or adjusted for renal dysfunction, q6h) for 5–14 days. The primary end point was clinical response for clinically evaluable (CE) subjects at test-of-cure (TOC) assessment. Results Four hundred and seventy subjects were randomized; 232 in the tigecycline and 231 in the imipenem/cilastatin group were treated. Tigecycline was non-inferior to imipenem/cilastatin with respect to clinical response at TOC for all CE subjects, ie, the lower bound of the two-sided 95% CI (−12.0%, −1.4%) for the treatment difference in cure rate, tigecycline (89.9%) minus imipenem/cilastatin (96.6%), was >−15%. As non-inferiority was concluded in the CE population, superiority of tigecycline over imipenem/cilastatin and superiority of imipenem/cilastatin over tigecycline were tested on the CE and the modified intent-to-treat (mITT) populations according to pre-specified statistical criteria, and neither could be demonstrated (the cure rate was 82.8% vs 88.7%, difference −6.0% [−12.8%, 0.8%], for the mITT population). The subject-level microbiological response rate at TOC for the microbiologically evaluable population was 88.0% (110/125) vs 95.3% (102/107, difference −7.3% [−15.2%, 0.5%]). Nausea, drug ineffectiveness, postoperative wound infection, vomiting, and pyrexia were the most common adverse events in tigecycline-treated subjects; pyrexia, nausea, vomiting, and increased alanine aminotransferase and aspartate aminotransferase levels were most common in imipenem/cilastatin-treated subjects; none were unanticipated. Conclusion Tigecycline was non-inferior to imipenem/cilastatin in treating hospitalized adult patients with cIAI. Superiority of tigecycline over imipenem/cilastatin or imipenem/cilastatin over tigecycline could not be demonstrated. Safety was consistent with the known profile for tigecycline. ClinicalTrials.gov identifier NCT01721408.
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Affiliation(s)
- Yijian Chen
- Institute of Antibiotics, Huashan Hospital Fudan University, Shanghai, China, .,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, China,
| | - Demei Zhu
- Institute of Antibiotics, Huashan Hospital Fudan University, Shanghai, China, .,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, China,
| | - Yingyuan Zhang
- Institute of Antibiotics, Huashan Hospital Fudan University, Shanghai, China, .,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, China,
| | - Yongjie Zhao
- Department of General Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Gang Chen
- Department of Hepatobiliary Surgery, First People's Hospital of Kunming, Kunming, China
| | - Ping Li
- Department of General Surgery, Sichuan Provincial People's Hospital, Chengdu, China
| | - Lihong Xu
- Pfizer (China) Research & Development Co, Ltd, Shanghai, China
| | - Ping Yan
- Pfizer (China) Research & Development Co, Ltd, Shanghai, China
| | | | - Xiajun Xu
- Pfizer (China) Research & Development Co, Ltd, Shanghai, China
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285
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Lalisang TJM, Usman N, Hendrawidjaya I, Handaya AY, Nasution S, Saunar RY, Loho T, Karuniawati A, Moenadjat Y, Widyahening IS. Clinical Practice Guidelines in Complicated Intra-Abdominal Infection 2018: An Indonesian Perspective. Surg Infect (Larchmt) 2018; 20:83-90. [PMID: 30427771 DOI: 10.1089/sur.2018.120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The occurrence of complicated intra-abdominal infections (cIAI) remains high despite system improvement in accordance with Joint Commission International because of heterogeneity of management. However, published clinical practice guidelines (CPGs) were not feasible to be implemented because these guidelines were not specific to Indonesian characteristics. Thus, a national CPG should be developed to minimize heterogeneity in the management of cIAI in Indonesia. METHODS We developed a CPG on cIAI through the adaptation of published CPGs. The process proceeded in steps recommended by ADAPTE. Published CPGs were critically appraised using Appraisal of Guidelines for Research and Evaluation (AGREE) II critical appraisal tools. For a specific updated CPG, the analysis was performed using Checklist for the Reporting of Updated Guidelines (CheckUp). Appropriate statements and recommendations in selected CPGs were adapted into our CPG with consideration of Indonesian characteristics. The recommendations were established by the hierarchy of evidence on Grading of Recommendations Assessment, Development and Evaluation (GRADE). The approval of the recommendation draft was performed using the Delphi method. RESULTS Sixty-eight full-text guidelines were downloaded from several sites. Thirty-three CPGs were related to intra-abdominal infection and 18 others were specific on CPG on intra-abdominal infection and cIAI. On review of these 18 CPGs, 13 were strongly recommended, three were recommended, and two were not recommended. On review updated CPGs, five updated CPGs were found, all with the same score. Two of the strongly recommended updated CPGs had been published in 2016 and 2017, i.e. recommendations by the World Society of Emergency Surgery 2016 consensus conference and revised CPG of the Surgical Site Infection Society. There were a total of 84 statements and recommendations developed and approved by the task force through using the Delphi method. CONCLUSIONS This guideline summarizes the definition, classification, pathophysiology, etiology, risk factors, assessments, and management of cIAI. Evidence-based recommendations have been developed with consideration of Indonesian-specific characteristics.
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Affiliation(s)
- Toar J M Lalisang
- 1 Department of Surgery, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo General Hospital , Jakarta, Indonesia
| | - Nurhayat Usman
- 2 Department of Surgery, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital , Bandung, Indonesia
| | - Iswanto Hendrawidjaya
- 3 Department of Surgery, Faculty of Medicine, Universitas Airlangga, Soetomo Hospital , Surabaya, Indonesia
| | - Adeodatus Y Handaya
- 4 Department of Surgery, Faculty of Medicine, Universitas Gajah Mada, Sardjito General Hospital , Yogyakarta, Indonesia
| | - Safruddin Nasution
- 5 Department of Surgery, Faculty of Medicine, Universitas Sumatera Utara, Adam Malik General Hospital , Medan, Indonesia
| | - Rofi Y Saunar
- 6 Department of Surgery, Fatmawati General Hospital , Jakarta, Indonesia
| | - Tonny Loho
- 7 Department of Clinical Pathology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo General Hospital , Jakarta, Indonesia
| | - Anis Karuniawati
- 8 Department of Clinical Microbiology , Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Yefta Moenadjat
- 1 Department of Surgery, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo General Hospital , Jakarta, Indonesia
| | - Indah S Widyahening
- 9 Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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286
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Kim IK, Lee JG. Antibiotic duration can be shortened in postoperative intra-abdominal infection. J Thorac Dis 2018; 10:S3182-S3183. [PMID: 30370107 DOI: 10.21037/jtd.2018.07.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Im-Kyung Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
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287
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Pochhammer J, Köhler J, Schäffer M. Colorectal Surgical Site Infections and Their Causative Pathogens: Differences between Left- and Right-Side Resections. Surg Infect (Larchmt) 2018; 20:62-70. [PMID: 30358512 DOI: 10.1089/sur.2018.143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs), after colorectal resection, pose a significant burden. Recognition of the spectrum of potentially involved pathogens is crucial for determining correct antibiotic prophylaxis. This study aimed to determine whether the distribution of SSI-associated pathogens depends on the location of the colorectal resection. METHODS We retrospectively categorized 2713 consecutive colon resections as left- or right-side operations, identified patients having concurrent peritonitis or development of postoperative SSIs and peritonitis, and assigned all subcutaneously and intra-abdominally isolated pathogens according to the location of the resection. RESULTS Gram-positive cocci (especially enterococci) and gram-negative bacilli (especially Pseudomonas aeruginosa) were isolated more frequently from patients in whom SSIs developed after left-side resections than after right-side resections (52.5% vs. 32.6%, p < 0.01 and 15.9% vs. 6.7%, p < 0.01, respectively); enterococci were the causative organisms in a large percentage of SSIs (46.3%). Moreover, intra-abdominal P. aeruginosa and Candida spp. were isolated more frequently during left-side resections than during right-side operations in patients with peritonitis (15.8% vs. 6.3%, p = 0.02 and 14.3% vs. 5.3%, p = 0.02, respectively). CONCLUSIONS Our results indicate that differences exist in the distribution of pathogens after left- or right-side colorectal resections. Our data further suggest that gram-positive cocci play an important role in SSIs occurring after colorectal resections; therefore, antibiotic prophylaxis should emphasize their coverage. Further, enterococcal coverage may be especially advantageous during left-side resections.
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Affiliation(s)
- Julius Pochhammer
- Department of Visceral, General, and Thoracic Surgery, Marienhospital Stuttgart , Stuttgart, Germany
| | - Joachim Köhler
- Department of Visceral, General, and Thoracic Surgery, Marienhospital Stuttgart , Stuttgart, Germany
| | - Michael Schäffer
- Department of Visceral, General, and Thoracic Surgery, Marienhospital Stuttgart , Stuttgart, Germany
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288
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Hornor MA, Liu JY, Hu QL, Ko CY, Wick E, Maggard-Gibbons M. Surgical Technical Evidence Review for Acute Appendectomy Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg 2018; 227:605-617.e2. [PMID: 30316962 DOI: 10.1016/j.jamcollsurg.2018.09.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Melissa A Hornor
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; American College of Surgeons, Chicago, IL.
| | - Jessica Y Liu
- American College of Surgeons, Chicago, IL; Department of Surgery, Emory University, Atlanta, GA
| | - Q Lina Hu
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
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289
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Huston JM, Zuckerbraun BS, Moore LJ, Sanders JM, Duane TM. Antibiotics versus No Antibiotics for the Treatment of Acute Uncomplicated Diverticulitis: Review of the Evidence and Future Directions. Surg Infect (Larchmt) 2018; 19:648-654. [DOI: 10.1089/sur.2018.115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Jared M. Huston
- Departments of Surgery and Science Education, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Brian S. Zuckerbraun
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Laura J. Moore
- Department of Surgery, The University of Texas McGovern Medical School, Houston, Texas
| | - James M. Sanders
- Department of Pharmacy and John Peter Smith Health Network, Fort Worth, Texas
| | - Therese M. Duane
- Department of Surgery, John Peter Smith Health Network, Fort Worth, Texas
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290
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Huang J, Ren J, Brakert L, Jiao J, Liu Q, Wang G, Wu X, Damink SWMO. A New Scoring System to Predict Blood Stream Infections in Patients with Complicated Intra-Abdominal Infections: Experience from a Tertiary Referral Hospital in China. Surg Infect (Larchmt) 2018; 19:459-466. [PMID: 29768131 DOI: 10.1089/sur.2017.243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND This purpose of this study was to investigate the effects of blood stream infections (BSIs) on the prognosis of patients with complicated intra-abdominal infections (IAIs) and to make predictions based on patients' characteristics on admission. PATIENTS AND METHODS One hundred eighty-seven patients with complicated IAI in 2014 and 2015 were included in our retrospective analysis, except for those diagnosed with central line-associated blood stream infections (CLABSIs). Patients with BSIs were compared with patients without BSIs. Multivariable logistic regression was applied to identify factors associated with BSIs and also the subtypes of BSIs. The predictive score systems were established further. RESULTS Seventy-four patients (39.6%) with complicated IAIs developed BSIs after admission. Four factors evaluated on admission were associated independently with BSIs including alanine aminotransferase (ALT) ≥66 U/L (two scores), insensitivity to initial empirical antibiotic agents (IIEA; three scores), Sepsis-Related Organ Failure Assessment (SOFA) score of two or more (three scores), and generalized peritonitis (four scores). A total score of five or more was regarded as the critical value in the combined test to predict BSIs, with a sensitivity of 0.78 and a specificity of 0.73. Blood stream infections were further divided as secondary BSIs and non-secondary BSIs. The risk factors of secondary BSIs included IIEA (three scores), SOFA score of two or more (five scores), and generalized peritonitis (eight scores), where a total score of nine or more was regarded as the critical value in the combined test, with a sensitivity of 0.68 and a specificity of 0.87, whereas the risk factors of non-secondary BSIs included IIEA (three scores), SOFA score of two or more (three scores) and procalcitonin (PCT) ≥0.43 mcg/L (three scores), where a total score of six or more was regarded as the critical value in the combined test, with a sensitivity of 0.75 and a specificity of 0.70. Moreover, BSIs were linked with the worse clinical outcomes in organ functions, hospitalization costs, and mortality. CONCLUSIONS Our new scoring methods may have potential advantages on the early prediction and recognition of BSIs in patients with complicated IAIs.
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Affiliation(s)
- Jinjian Huang
- 1 Department of Surgery, Jinling Hospital , Nanjing, China .,3 Medical School of Southeast University , Nanjing, China
| | - Jianan Ren
- 1 Department of Surgery, Jinling Hospital , Nanjing, China
| | - Luise Brakert
- 2 University Medical Center of Hamburg-Eppendorf , Hamburg, Germany
| | - Jiao Jiao
- 3 Medical School of Southeast University , Nanjing, China
| | - Qinjie Liu
- 1 Department of Surgery, Jinling Hospital , Nanjing, China
| | - Gefei Wang
- 1 Department of Surgery, Jinling Hospital , Nanjing, China
| | - Xiuwen Wu
- 1 Department of Surgery, Jinling Hospital , Nanjing, China
| | - Steven W M Olde Damink
- 4 Department of Surgery, Maastricht University Medical Centre , Maastricht, The Netherlands
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291
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Pochhammer J, Kramer A, Schäffer M. [Enterococci and surgical site infections : Causal agent or harmless commensals?]. Chirurg 2018; 88:377-384. [PMID: 28233041 DOI: 10.1007/s00104-017-0388-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The role of enterococci in the context of peritonitis and surgical site infections (SSI) has not yet been definitively clarified but enterococci are being detected more frequently. Numerous resistances reduce the available antibiotic options. OBJECTIVE This article gives an overview of the pathogenic importance of enterococci and of current recommendations for therapy and prophylaxis. On the basis of our own data we discuss the relevance of enterococci for SSI. MATERIAL AND METHODS All colorectal resections carried out between January 2008 and September 2016 were retrospectively documented. Revision surgery, SSI and intra-abdominally or subcutaneously detected pathogens were recorded. RESULTS A total of 2713 interventions were evaluated with 28.3% having primary peritonitis. In 587 patients (21.6%) SSI followed, and pathogen determination was possible in 431 cases (73.4%). Enterococci were frequently found in re-operations (58.4%) and SSI (46.1%), with E. faecalis and E. faecium in approximately equal proportions. If intra-abdominal enterococci were detectable in patients with primary peritonitis, it was more common to develop SSI and enterococci were more frequently detected subcutaneously. Enterococci in SSI were found to be significantly more frequent in left hemicolectomies as well as in pre-existing renal insufficiency. CONCLUSION It can be inferred that enterococci are not adequately covered by commonly used perioperative antibiotic therapy or preoperative prophylaxis, which increases the risk for SSI by enterococci. This could be favored by selection of these pathogens due to the use of antibiotics without enterococcal efficacy (e. g. cephalosporins). The consideration in the choice of perioperative antibiotic prophylaxis by the additional administration of ampicillin or vancomycin could be advantageous.
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Affiliation(s)
- J Pochhammer
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Marienhospital Stuttgart, Vinzenz von Paul Kliniken, Böheimstr. 39, 70199, Stuttgart, Deutschland.
| | - A Kramer
- Institut für Hygiene und Umweltmedizin, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - M Schäffer
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Marienhospital Stuttgart, Vinzenz von Paul Kliniken, Böheimstr. 39, 70199, Stuttgart, Deutschland
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292
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Gonzalez G, Montemayor E, Sanders JM, Burton M, Tessier JM, Duane TM. Measuring Provider Compliance with an Institution-Based Clinical Pathway for Diverticulitis Using Radiologic Criteria. Surg Infect (Larchmt) 2018; 19:655-660. [PMID: 30179571 DOI: 10.1089/sur.2018.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Diverticulitis remains a common disease encountered in the acute care setting. Management strategies have been developed to guide treatment decisions based on imaging. By using a multi-faceted clinical pathway approach, a standardized method of diagnosing and categorizing disease severity can be performed in order to guide appropriate management. This study evaluated provider compliance with an institutional clinical pathway designed to guide management of diverticulitis. METHODS An institutional clinical pathway was developed to manage diverticulitis, including radiologic classification, primary service line assignment, interventional strategies, and antimicrobial treatment. To assess provider compliance with the algorithm, we queried the institutional acute diverticulitis database for patients admitted from May 19, 2016 to February 8, 2017, which identified 83 patients. Provider compliance with the pathway was assessed using subgroup analysis of radiologic documentation (modified Neff [mNeff] classification), primary service assignment, and interventions (i.e., interventional radiology [IR] and antimicrobial agents). RESULTS The cohort represented a diverse group of mNeff classifications, predominantly Stage 0. Surgical interventions occurred in 10.8% of the cohort. Antimicrobial agents were administered to 88.0% and 78.3% of the outpatients and inpatients, respectively. Patients received a total duration of antimicrobial therapy (mean ± standard deviation [SD]) of 10.2 ± 5.1 days. Overall compliance occurred in 10% of the patients. Compliance with radiologic documentation, antimicrobial choice, and antimicrobial duration were 90.4%, 20.5%, and 69.9%, respectively. CONCLUSIONS Overall compliance with the clinical pathway was poor, except as it related to compliance with radiologic documentation, appropriate assignment to surgical service line, and antimicrobial duration. These results suggest areas for future improvement to augment compliance with the clinical pathway.
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Affiliation(s)
- Gabriel Gonzalez
- 1 JPS Health Network , Fort Worth, Texas.,2 Baylor Scott & White , Dallas, Texas
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293
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Tan A, Rouse M, Kew N, Qin S, La Paglia D, Pham T. The appropriateness of ceftriaxone and metronidazole as empirical therapy in managing complicated intra-abdominal infection-experience from Western Health, Australia. PeerJ 2018; 6:e5383. [PMID: 30128188 PMCID: PMC6098677 DOI: 10.7717/peerj.5383] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/16/2018] [Indexed: 12/29/2022] Open
Abstract
Purpose This study aims to assess the microbiological profile, antimicrobial susceptibility and adequacy of intravenous ceftriaxone and metronidazole as empirical therapy for surgical patients presenting with complicated intra-abdominal infection. Methods This retrospective audit reviews the microbiological profile and sensitivity of intra-abdominal cultures from adult patients with complicated intra-abdominal infection who presented to the emergency department at Western Health (Melbourne, Australia) between November 2013 and June 2017. Using the hospital’s database, an audit was completed using diagnosis related group (DRG) coded data. Ethics approval has been granted by the Western Health Human Research Ethics Committee. Results are stratified according to surgical conditions (appendicitis, cholecystitis, sigmoid diverticulitis and bowel perforation). The antimicrobial coverage of ceftriaxone and metronidazole is evaluated against these microbial profiles. Results A total of 1,412 patients were identified using DRG codes for intra-abdominal infection. All patients with microscopy and sensitivity results were included in the study. Patients without these results were excluded. 162 patients were evaluable. 180 microbiological cultures were performed through surgical intervention or radiologically guided aspiration of the intra-abdominal infection. Single or multiple pathogens were identified in 137 cultures. The most commonly identified pathogens were mixed anaerobes (12.6%), Escherichia coli (E. coli) (12.1%), mixed coliforms (11.6%) and Pseudomonas aeruginosa (7%). Other common pathogens (6% each) included Enterococcus faecalis, Streptococcus anginosus, Vancomycin-resistant Enterococci (VRE) and Extended Spectrum Beta-Lactamases (ESBL) producing E. coli. Organisms isolated in our study are consistent with existing literature. However, a significant proportion of antibiotic resistant organisms was identified in cases of perforated bowel and sigmoid diverticulitis. Broader spectrum antimicrobial therapy should therefore be considered in lieu of ceftriaxone and metronidazole in these cases. Ceftriaxone and metronidazole remain as appropriate empirical therapy for patients who presented with perforated appendicitis and cholecystitis. Discussion The empirical regime of ceftriaxone and metronidazole remains appropriate for intra-abdominal infection secondary to appendicitis and cholecystitis. In cases involving perforated small and large bowel, including complicated sigmoid diverticulitis, the judicious use of ceftriaxone and metronidazole is recommended.
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Affiliation(s)
- Andrew Tan
- Department of General Surgery, Western Health, Melbourne, Victoria, Australia
| | - Michael Rouse
- Department of General Surgery, Western Health, Melbourne, Victoria, Australia
| | - Natalie Kew
- Department of General Surgery, Western Health, Melbourne, Victoria, Australia
| | - Sharon Qin
- Department of General Surgery, Western Health, Melbourne, Victoria, Australia
| | - Domenic La Paglia
- Department of General Surgery, Western Health, Melbourne, Victoria, Australia
| | - Toan Pham
- Department of General Surgery, Western Health, Melbourne, Victoria, Australia
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294
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Pisano M, Zorcolo L, Merli C, Cimbanassi S, Poiasina E, Ceresoli M, Agresta F, Allievi N, Bellanova G, Coccolini F, Coy C, Fugazzola P, Martinez CA, Montori G, Paolillo C, Penachim TJ, Pereira B, Reis T, Restivo A, Rezende-Neto J, Sartelli M, Valentino M, Abu-Zidan FM, Ashkenazi I, Bala M, Chiara O, De' Angelis N, Deidda S, De Simone B, Di Saverio S, Finotti E, Kenji I, Moore E, Wexner S, Biffl W, Coimbra R, Guttadauro A, Leppäniemi A, Maier R, Magnone S, Mefire AC, Peitzmann A, Sakakushev B, Sugrue M, Viale P, Weber D, Kashuk J, Fraga GP, Kluger I, Catena F, Ansaloni L. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg 2018; 13:36. [PMID: 30123315 PMCID: PMC6090779 DOI: 10.1186/s13017-018-0192-3] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/28/2018] [Indexed: 02/07/2023] Open
Abstract
ᅟ Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC). Methods The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017. Results CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted. With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value. Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required. Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation. Conclusions The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.
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Affiliation(s)
- Michele Pisano
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Luigi Zorcolo
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Cecilia Merli
- Unit of Emergency Medicine Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
| | | | - Elia Poiasina
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Marco Ceresoli
- 5Department of General Surgery, School of Medicine, University of Milano, Milan, Italy
| | | | - Niccolò Allievi
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | | | - Federico Coccolini
- Unit of General and Emergency Surgery, Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
| | - Claudio Coy
- 9Colorectal Unit, Campinas State University, Campinas, SP Brazil
| | - Paola Fugazzola
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | | | | | - Ciro Paolillo
- Emergency Department Udine Healthcare and University Integrated Trust, Udine, Italy
| | | | - Bruno Pereira
- 14Department of Surgery, University of Campinas, Campinas, Brazil
| | - Tarcisio Reis
- Oncology Surgery and Intensive Care, Oswaldo Cruz Hospital, Recife, Brazil
| | - Angelo Restivo
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Joao Rezende-Neto
- 16Department of Surgery Division of General Surgery, University of Toronto, Toronto, Canada
| | | | - Massimo Valentino
- 18Radiology Unit Emergency Department, S. Antonio Abate Hospital, Tolmezzo, UD Italy
| | - Fikri M Abu-Zidan
- 19Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Miklosh Bala
- 21Trauma and Acute Care Surgery Unit Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | | | - Nicola De' Angelis
- 22Unit of Digestive Surgery, HPB Surgery and Liver Transplant Henri Mondor Hospital, Créteil, France
| | - Simona Deidda
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Belinda De Simone
- Department of General and Emergency Surgery Cannes' Hospital Cannes, Cedex, Cannes, France
| | | | - Elena Finotti
- Department of General Surgery ULSS5 del Veneto, Adria, (RO) Italy
| | - Inaba Kenji
- 25Division of Trauma & Critical Care University of Southern California, Los Angeles, USA
| | - Ernest Moore
- 26Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO USA
| | - Steven Wexner
- Digestive Disease Center, Department of Colorectal Surgery Cleveland Clinic Florida, Tallahassee, USA
| | - Walter Biffl
- 28Acute Care Surgery The Queen's Medical Center, Honolulu, HI USA
| | - Raul Coimbra
- 29Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego Health Sciences, San Diego, USA
| | - Angelo Guttadauro
- 5Department of General Surgery, School of Medicine, University of Milano, Milan, Italy
| | - Ari Leppäniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Stefano Magnone
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Alain Chicom Mefire
- 32Department of Surgery and Obs/Gyn, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Andrew Peitzmann
- 33Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Boris Sakakushev
- 34General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Dieter Weber
- 37Trauma and General Surgeon, Royal Perth Hospital, Perth, Australia
| | - Jeffry Kashuk
- 38Surgery and Critical Care Assuta Medical Centers, Tel Aviv, Israel
| | - Gustavo P Fraga
- 39Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Ioran Kluger
- 40Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
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295
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Anderson KT, Bartz-Kurycki MA, Kawaguchi AL, Austin MT, Holzmann-Pazgal G, Kao LS, Lally KP, Tsao K. Home Antibiotics at Discharge for Pediatric Complicated Appendicitis: Friend or Foe? J Am Coll Surg 2018; 227:247-254. [PMID: 29680415 DOI: 10.1016/j.jamcollsurg.2018.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
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296
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García-Marín A, Pérez-López M, Martínez-Guerrero E, Rodríguez-Cazalla L, Compañ-Rosique A. Microbiologic Analysis of Complicated and Uncomplicated Acute Appendicitis. Surg Infect (Larchmt) 2018; 19:83-86. [PMID: 29303686 DOI: 10.1089/sur.2017.210] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Microbiologic studies suggest that complicated (CAA) and uncomplicated (UAA) acute appendicitis are different entities. Routine peritoneal fluid cultures continue to be controversially related to a low positive rate, found mainly in UAA; to isolation of typical micro-organisms with expected susceptibilities; and to a community-acquired intra-abdominal infection. The aim of this study was to describe microbiologic isolates in CAA and UAA and the usefulness of peritoneal fluid cultures to determine the susceptibilities to our antibiotic therapy guidelines. METHODS This study was a retrospective review of a prospective database collected at University San Juan Hospital (Spain) between June 2014 and June 2017. Complicated acute appendicitis was defined as gangrenous or perforated, whereas UAA was defined as phegmonous or suppurative. Our antibiotic recommendations are amoxicillin-clavulanic acid and in patients with β-lactam allergies, metronidazole plus aztreonam, and an aminoglycoside (gentamicin or tobramycin). Microbiologic cultures were performed in 264 patients, 157 with a CAA and 107 with a UAA. RESULTS The positive culture rate was significantly higher in CAA (59%) than in UAA (24.3%). Gram-positive cocci (51.6% CAA; 23.1% UAA), including Streptococcus constellatus (29% CAA; 3.8% UAA), and anaerobes (67.7% CAA; 42.3% UAA) were significantly more common in CAA. The rates of antibiotic resistance were amoxicillin-clavulanic acid 14% (17.2% CAA; 3.8% UAA), gentamicin or tobramycin 8.4% (9.7% CAA; 3.8% UAA), ciprofloxacin 5.9% (6.5% CAA; 3.8% UAA), and ertapenem 10.9% (14% CAA; 0 UAA). CONCLUSIONS The culture-positive rate was higher in CAA, with different isolates and susceptibilities than in UAA, identifying a higher frequency of gram-positive cocci (including S. constellatus) and anaerobes. We recommend obtaining peritoneal fluid cultures in CAA, which frequently will lead to a change in the antimicrobial drug therapy guidelines, creating specific recommendations in AA.
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Affiliation(s)
- Andrés García-Marín
- 1 Department of Pathology and Surgery, Miguel Hernandez University, Elche, Spain; Department of Surgery, University Hospital San Juan de Alicante , Sant Joan d'Alacant, Spain
| | - Mercedes Pérez-López
- 2 Surgical Nursery, University Hospital San Juan de Alicante , Sant Joan d'Alacant, Spain
| | - Elena Martínez-Guerrero
- 1 Department of Pathology and Surgery, Miguel Hernandez University, Elche, Spain; Department of Surgery, University Hospital San Juan de Alicante , Sant Joan d'Alacant, Spain
| | - Lorena Rodríguez-Cazalla
- 1 Department of Pathology and Surgery, Miguel Hernandez University, Elche, Spain; Department of Surgery, University Hospital San Juan de Alicante , Sant Joan d'Alacant, Spain
| | - Antonio Compañ-Rosique
- 1 Department of Pathology and Surgery, Miguel Hernandez University, Elche, Spain; Department of Surgery, University Hospital San Juan de Alicante , Sant Joan d'Alacant, Spain
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297
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Horn CB, Coleoglou Centeno AA, Rasane RK, Aldana JA, Fiore NB, Zhang Q, Torres M, Mazuski JE, Ilahi ON, Punch LJ, Bochicchio GV. Pre-Operative Anti-Fungal Therapy Does Not Improve Outcomes in Perforated Peptic Ulcers. Surg Infect (Larchmt) 2018; 19:587-592. [PMID: 30036134 DOI: 10.1089/sur.2018.058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND With the advent of anti-Helicobacter pylori therapy, hospital admissions for peptic ulcer disease (PUD) have declined significantly since the 1990s. Despite this, operative treatment of PUD still is common. Although previous papers suggest that Candida in peritoneal fluid cultures may be associated with worse outcomes in patients with perforated peptic ulcers (PPUs), post-operative anti-fungal therapy has not been effective. We hypothesized that pre-operative anti-fungal drugs improve outcomes in patients with PPUs undergoing operative management. PATIENTS AND METHODS A prospectively maintained Acute and Critical Care Surgery (ACCS) database spanning 2008-2015 and including more than 7,000 patients was queried for patients with PPUs. Demographics and clinical outcomes were abstracted. Pre-operative anti-fungal use, intra-operative peritoneal fluid cultures, and infectious outcomes were abstracted manually. We compared outcomes and the presence of fungal infections in patients receiving peri-operative anti-fungal drugs in the entire cohort and in patients with intra-operative peritoneal fluid cultures. Frequencies were compared by the Fisher exact or χ2 test as appropriate. The Student's t-test was used for continuous variables. RESULTS There were 107 patients with PPUs who received operative management; 27 (25.2%) received pre-operative anti-fungal therapy; 33 (30.8%) received peritoneal fluid culture, and 17 cultures (51.5%) were positive for fungus. The presence of fungus in the cultures did not affect the outcomes. There were no differences in length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, 30-day re-admission rates, or rates of intra-abdominal abscess formation or fungemia in patients who received pre-operative anti-fungal drugs regardless of the presence of fungi in the peritoneal fluid. CONCLUSION Candida has been recovered in 29%-57% of peritoneal fluid cultures in patients with PPUs. However, no studies have evaluated pre-operative anti-fungal therapy in PPUs. Our data suggest that pre-operative anti-fungal drugs are unnecessary in patients undergoing operative management for PPU.
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Affiliation(s)
- Christopher B Horn
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | | | - Rohit K Rasane
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Jose A Aldana
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Nicholas B Fiore
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Qiao Zhang
- 2 Institute for Informatics, Washington University in St Louis , St. Louis, Missouri
| | - Marlon Torres
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - John E Mazuski
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Obeid N Ilahi
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Laurie J Punch
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Grant V Bochicchio
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
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298
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Clinical characteristics and prognosis of bacteraemia during postoperative intra-abdominal infections. Crit Care 2018; 22:175. [PMID: 29980218 PMCID: PMC6035454 DOI: 10.1186/s13054-018-2099-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/19/2018] [Indexed: 12/02/2022] Open
Abstract
Background Bloodstream infections of abdominal origin are usually associated with poor prognosis. We assessed the clinical and microbiological characteristics of critically ill patients admitted to the intensive care unit (ICU) for postoperative intra-abdominal infection (PIAI) and analysed the influence of bacteraemia on their outcome. Methods All consecutive PIAI patients admitted to the ICU between 1999 and 2014 were prospectively analysed. Bacteraemic patients (at least one positive blood culture in the 24 h preceding/following surgery) were compared with non-bacteraemic patients. Demographic characteristics, underlying disease, severity scores at the time of reoperation, microbiological results, therapeutic management, outcome, and survival were recorded. Results are expressed as median (interquartile range (IQR)) or proportions. Results Overall, 343 patients (54% male, 62 (49–73) years old) with PIAI were analysed, including 64 (19%) bacteraemic patients. Immunosuppression and cancer were more frequent in bacteraemic patients (p < 0.001 in both cases). No difference between groups was observed for the characteristics of initial surgery. Time to reoperation, site, and cause of PIAI were similar in both groups. At the time of reoperation, Sequential Organ Failure Assessment (SOFA) score was higher in bacteraemic patients (8 (6–10) versus 7 (4–10); p < 0.05). A predominance of Gram-positive (34%) and Gram-negative (47%) bacteria were recovered from blood cultures (polymicrobial bacteraemia in 9 (14%) patients and bacteraemia involving multidrug-resistant organisms in 14 (22%) patients). In multivariate analysis, risk factors for bacteraemia were immunosuppression or cancer, high SOFA score, and E. coli in peritoneal samples. Bacteraemia did not impact the management (with similar results for the adequacy of antibiotic therapy, anti-infective agents used, de-escalation or duration of therapy in both groups). Neither hospital mortality nor morbidity criteria differed between groups. Risk factors for mortality in multivariate analysis were urgent initial surgery, high Simplified Acute Physiology Score (SAPS) II score and documented antifungal therapy, but not perioperative bacteraemia. Conclusions In this ICU population, bacteraemia did not change the overall management of patients with PIAI. Our data suggest that bacteraemic patients do not require a specific management.
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Foolad F, Nagel JL, Eschenauer G, Patel TS, Nguyen CT. Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management. J Antimicrob Chemother 2018; 72:3232-3244. [PMID: 29177489 DOI: 10.1093/jac/dkx266] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.
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Affiliation(s)
- Farnaz Foolad
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Jerod L Nagel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Gregory Eschenauer
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA.,College of Pharmacy, University of Michigan, 428 Church St., Ann Arbor, MI 48109, USA
| | - Twisha S Patel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Cynthia T Nguyen
- Department of Pharmacy, University of Chicago Medicine, 5841 S. Maryland Ave. MC0010, Chicago, IL 60637, USA
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300
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van den Boom AL, de Wijkerslooth EML, Mauff KAL, Dawson I, van Rossem CC, Toorenvliet BR, Wijnhoven BPL. Interobserver variability in the classification of appendicitis during laparoscopy. Br J Surg 2018; 105:1014-1019. [PMID: 29663311 PMCID: PMC6033013 DOI: 10.1002/bjs.10837] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/27/2017] [Accepted: 01/14/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The intraoperative classification of appendicitis dictates the patient's postoperative management. Prolonged antibiotic prophylaxis is recommended for complex appendicitis (gangrenous, perforated, abscess), whereas preoperative prophylaxis suffices for simple appendicitis. Distinguishing these two conditions can be challenging. The aim of this study was to assess interobserver variability in the classification of appendicitis during laparoscopy. METHODS Short video recordings taken during laparoscopy for suspected appendicitis were shown to surgeons and surgical residents. They were asked to: classify the appendix as indicative of no, simple or complex appendicitis; categorize the appendix as normal, phlegmonous, gangrenous, perforated and/or abscess; and decide whether they would prescribe postoperative antibiotics. Inter-rater reliability was evaluated using Fleiss' κ score and the S* statistic. RESULTS Some 80 assessors participated in the study. Video recordings of 20 patients were used. Interobserver agreement was minimal for both the classification of appendicitis (κ score 0·398, 95 per cent c.i. 0·385 to 0·410) and the decision to prescribe postoperative antibiotic treatment (κ score 0·378, 0·362 to 0·393). Agreement was slightly higher when published criteria were applied (κ score 0·552, 0·537 to 0·568). CONCLUSION There is considerable variability in the intraoperative classification of appendicitis and the decision to prescribe postoperative antibiotic treatment.
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Affiliation(s)
- A. L. van den Boom
- Department of SurgeryErasmus MC – University Medical CentreRotterdamThe Netherlands
| | | | - K. A. L. Mauff
- Department of BiostatisticsErasmus MC – University Medical CentreRotterdamThe Netherlands
| | - I. Dawson
- Department of SurgeryIJsselland ZiekenhuisCapelle a/d IJsselThe Netherlands
| | - C. C. van Rossem
- Department of SurgeryMaasstad ZiekenhuisRotterdamThe Netherlands
| | | | - B. P. L. Wijnhoven
- Department of SurgeryErasmus MC – University Medical CentreRotterdamThe Netherlands
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