The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

Coagulative biomarkers on admission to the ICU predict acute kidney injury and mortality in patients with septic shock caused by intra-abdominal infection

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.

Antibiotic Resistance in Community-Acquired Intra-Abdominal Infections: Diabetes Mellitus as a Risk Factor

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.

Variation in Classification and Postoperative Management of Complex Appendicitis: A European Survey

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.

Early Laparoscopic Washout may Resolve Persistent Intra-abdominal Infection Post-appendicectomy

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.

Ceftolozane/tazobactam for the treatment of complicated intra-abdominal and urinary tract infections: current perspectives and place in therapy

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.

Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis

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.

Empirical metronidazole for patients with severe bacterial infection: A systematic review with meta-analysis and trial sequential analysis

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.

Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions

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 37^th 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.

An Evaluation of Guideline Concordance in the Management of Intra-Abdominal Infections

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.

Usefulness of Gram stain examination of peritoneal fluid in postoperative peritonitis to guide empirical antibiotherapy

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.

Comparison of Short-Course and Prolonged Antimicrobial Therapy in the Management of Intra-Abdominal Infections

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.

Epidemiology and outcomes of source control procedures in critically ill patients with intra-abdominal infection

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.

Methods of conservative antibiotic treatment of acute uncomplicated appendicitis: A systematic review

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.

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

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.

Disease burden of appendectomy for appendicitis: a population-based cohort study

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.

Nationwide observational study of mortality from complicated intra-abdominal infections and the role of bacterial cultures

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.

Comparative Effectiveness of Ceftriaxone plus Metronidazole versus Anti-Pseudomonal Antibiotics for Perforated Appendicitis in Children

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.

Catalase-Containing Silica Particles as Ultrasound-Based Hydrogen Peroxide Sensors to Determine Infected From Noninfected Fluid Collections in Humans

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.

Polymicrobial Bacteremia Involving Klebsiella pneumoniae in Patients with Complicated Intra-Abdominal Infections: Frequency, Co-Pathogens, Risk Factors, and Clinical Outcomes

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.

Prospective evaluation of a clinical response directed pathway for complicated appendicitis

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.

The impact of initial antibiotic treatment failure: real-world insights in patients with complicated, health care-associated intra-abdominal infection

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.

Treating Surgical Infections in Low- and Middle-Income Countries: Source Control, Then What?

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.

Rationalizing antimicrobial therapy in the ICU: a narrative review

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.

Fluoroquinolone-based versus β-lactam-based regimens for complicated intra-abdominal infections: a meta-analysis of randomised controlled trials

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.

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

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.

Chinese guidelines on the management of ascites and its related complications in cirrhosis

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.

Vancomycin in the treatment of adult intra-abdominal infections: do we have strong evidences?

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.

The Role of Ertapenem for the Treatment of Complicated Intra-abdominal Infections With a Positive Culture for Enterococcus faecalis

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.

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

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.

Clinical Practice Guidelines in Complicated Intra-Abdominal Infection 2018: An Indonesian Perspective

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.

Colorectal Surgical Site Infections and Their Causative Pathogens: Differences between Left- and Right-Side Resections

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.

A New Scoring System to Predict Blood Stream Infections in Patients with Complicated Intra-Abdominal Infections: Experience from a Tertiary Referral Hospital in China

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.

[Enterococci and surgical site infections : Causal agent or harmless commensals?]

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.

Measuring Provider Compliance with an Institution-Based Clinical Pathway for Diverticulitis Using Radiologic Criteria

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.

The appropriateness of ceftriaxone and metronidazole as empirical therapy in managing complicated intra-abdominal infection-experience from Western Health, Australia

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.

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

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.

Microbiologic Analysis of Complicated and Uncomplicated Acute Appendicitis

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.

Pre-Operative Anti-Fungal Therapy Does Not Improve Outcomes in Perforated Peptic Ulcers

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.

Clinical characteristics and prognosis of bacteraemia during postoperative intra-abdominal infections

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.

Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management

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.

Interobserver variability in the classification of appendicitis during laparoscopy

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.