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Katheria AC, El Ghormli L, Rice MM, Dorner RA, Grobman WA, Evans SR. Application of desirability of outcome ranking to the milking in non-vigorous infants trial. Early Hum Dev 2024; 189:105928. [PMID: 38211436 PMCID: PMC10922970 DOI: 10.1016/j.earlhumdev.2023.105928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/23/2023] [Accepted: 12/28/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVES Neonatal trials have traditionally used binary composite short-term (such as death or bronchopulmonary dysplasia) or longer-term (such as death or severe neurodevelopmental impairment) outcomes. We applied the Desirability Of Outcome Ranking (DOOR) method to rank the overall patient outcome by best (no morbidities) to worst (death). STUDY DESIGN Using a completed large multicenter trial (Milking In Non-Vigorous Infants [MINVI]) of umbilical cord milking (UCM) vs. early cord clamping (ECC), we applied the DOOR methodology to neonatal outcomes. Six outcomes were chosen and ranked: no interventions or NICU admission (most desirable); received initial cardiorespiratory support at birth; neonatal intensive care unit (NICU) admission for predefined criteria; mild hypoxic-ischemic encephalopathy (HIE); moderate to severe HIE; and death (least desirable). RESULTS 1524 non-vigorous newborns born between 35 and 42 weeks' gestation had data for analysis. The DOOR distribution was different between the UCM and ECC arms, with a significantly greater probability (55.8 % [95 % CI 53.1-58.5 %; p < 0.0001]) of a randomly selected neonate having a more desirable outcome if they were in the UCM arm. DOOR probabilities of averting individual adverse outcomes such as NICU admission for predefined criteria (52.8 %; 95%CI 50.5-55.1 %) and cardiorespiratory support (54.0 %; 95%CI 51.6-56.4 %) were significantly higher among those in the UCM group. CONCLUSION DOOR provides an overall assessment of the benefits and harms with greater insight than typical binary composite measures to clinicians and parents when evaluating an intervention. Future neonatal trials should consider the a priori use of the DOOR methodology to evaluate trial outcomes.
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Affiliation(s)
- Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States of America.
| | - Laure El Ghormli
- George Washington University Biostatistics Center, Washington, DC, United States of America
| | - Madeline M Rice
- George Washington University Biostatistics Center, Washington, DC, United States of America
| | - Rebecca A Dorner
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States of America
| | - William A Grobman
- Department of Obstetrics, Ohio State University, Columbus, OH, United States of America
| | - Scott R Evans
- George Washington University Biostatistics Center, Washington, DC, United States of America
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2
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Yek C, Lawandi A, Evans SR, Kadri SS. Which trial do we need? Optimal antibiotic duration for patients with sepsis. Clin Microbiol Infect 2023; 29:1232-1236. [PMID: 37230248 DOI: 10.1016/j.cmi.2023.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Christina Yek
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Alexander Lawandi
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Scott R Evans
- Biostatistics Center, George Washington University, Rockville, MD, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Bethesda, MD, USA.
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3
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Fry DE. Antibiotic Therapy Following Percutaneous Drainage of Intra-abdominal Abscess. Dis Colon Rectum 2023; 66:343-344. [PMID: 36395429 DOI: 10.1097/dcr.0000000000002676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Donald E Fry
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
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4
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The 2021 Dutch Working Party on Antibiotic Policy (SWAB) guidelines for empirical antibacterial therapy of sepsis in adults. BMC Infect Dis 2022; 22:687. [PMID: 35953772 PMCID: PMC9373543 DOI: 10.1186/s12879-022-07653-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Dutch Working Party on Antibiotic Policy (SWAB) in collaboration with relevant professional societies, has updated their evidence-based guidelines on empiric antibacterial therapy of sepsis in adults. METHODS Our multidisciplinary guideline committee generated ten population, intervention, comparison, and outcome (PICO) questions relevant for adult patients with sepsis. For each question, a literature search was performed to obtain the best available evidence and assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The quality of evidence for clinically relevant outcomes was graded from high to very low. In structured consensus meetings, the committee formulated recommendations as strong or weak. When evidence could not be obtained, recommendations were provided based on expert opinion and experience (good practice statements). RESULTS Fifty-five recommendations on the antibacterial therapy of sepsis were generated. Recommendations on empiric antibacterial therapy choices were differentiated for sepsis according to the source of infection, the potential causative pathogen and its resistance pattern. One important revision was the distinction between low, increased and high risk of infection with Enterobacterales resistant to third generation cephalosporins (3GRC-E) to guide the choice of empirical therapy. Other new topics included empirical antibacterial therapy in patients with a reported penicillin allergy and the role of pharmacokinetics and pharmacodynamics to guide dosing in sepsis. We also established recommendations on timing and duration of antibacterial treatment. CONCLUSIONS Our multidisciplinary committee formulated evidence-based recommendations for the empiric antibacterial therapy of adults with sepsis in The Netherlands.
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Salyer CE, Bergmann CB, Hotchkiss RS, Crisologo PA, Caldwell CC. Functional Characterization of Neutrophils Allows Source Control Evaluation in a Murine Sepsis Model. J Surg Res 2022; 274:94-101. [PMID: 35134595 PMCID: PMC9038647 DOI: 10.1016/j.jss.2021.12.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 12/01/2021] [Accepted: 12/27/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Current surgical guidelines for the treatment of intra-abdominal sepsis recommend interventional source control as the key element of therapy, alongside resuscitation and antibiotic administration. Past trials attempted to predict the success of interventional source control to assess whether further interventional therapy is needed. However, no predictive score could be developed. MATERIALS AND METHODS We utilized an established murine abdominal sepsis model, the cecal ligation and puncture (CLP), and performed a successful surgical source control intervention after full development of sepsis, the CLP-excision (CLP/E). We then sought to evaluate the success of the source control by characterizing circulating neutrophil phenotype and functionality 24 h postintervention. RESULTS We showed a significant relative increase of neutrophils and a significant absolute and relative increase of activated neutrophils in septic mice. Source control with CLP/E restored these numbers back to baseline. Moreover, main neutrophil functions, the acidification of cell compartments, such as lysosomes, and the production of Tumor Necrosis Factor-alpha (TNF-α), were impaired in septic mice but restored after CLP/E intervention. CONCLUSIONS Neutrophil characterization by phenotyping and evaluating their functionality indicates successful source control in septic mice and can serve as a prognostic tool. These findings provide a rationale for the phenotypic and functional characterization of neutrophils in human patients with infection. Further studies will be needed to determine whether a predictive score for the assessment of successful surgical source control can be established.
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Affiliation(s)
- Christen E Salyer
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Christian B Bergmann
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Richard S Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri
| | - Peter A Crisologo
- Division of Podiatric Surgery, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Charles C Caldwell
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
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6
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Napolitano LM. Intra-abdominal Infections. Semin Respir Crit Care Med 2022; 43:10-27. [PMID: 35172355 DOI: 10.1055/s-0041-1741053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Intra-abdominal infections (IAIs) are a common cause of sepsis, and frequently occur in intensive care unit (ICU) patients. IAIs include many diagnoses, including peritonitis, cholangitis, diverticulitis, pancreatitis, abdominal abscess, intestinal perforation, abdominal trauma, and pelvic inflammatory disease. IAIs are the second most common cause of infectious morbidity and mortality in the ICU after pneumonia. IAIs are also the second most common cause of sepsis in critically ill patients, and affect approximately 5% of ICU patients. Mortality with IAI in ICU patients ranges from 5 to 50%, with the wide variability related to the specific IAI present, associated patient comorbidities, severity of illness, and organ dysfunction and failures. It is important to have a comprehensive understanding of IAIs as potential causes of life-threatening infections in ICU patients to provide the best diagnostic and therapeutic care for optimal patient outcomes in the ICU.
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7
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Yan C, Cao J, Chen B, Guo C. Postoperative organ space infection (OSI) following appendectomy: early term evaluation for pediatric population. Updates Surg 2022; 74:1027-1033. [PMID: 34997547 DOI: 10.1007/s13304-021-01207-z] [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: 04/24/2021] [Accepted: 11/18/2021] [Indexed: 11/28/2022]
Abstract
No consensus has been reached on the duration of antibiotic prophylaxis for postoperative organ space infection (OSI) following appendectomy. This study investigated the influence of antibiotic administration on postoperative OSIs in children with complex appendicitis. A multicenter, retrospective study was conducted in patients with OSI following complicated appendicitis between 2017 and 2019 at 3 hospitals in China. The qualified patients were dichotomized into a long-duration antibiotic group (> 5.5 days) and a short-duration antibiotic group (< 5.5 days) based on the median duration (5.5 days) of antibiotic administration. Potential biases in baseline characteristics were managed using propensity score matching for the two groups. Primary and secondary outcomes were compared between the two groups. Propensity-matched analysis of the entire cohort revealed no significant effects in terms of the time to OSI resolution (p = 0.16) or recurrence (p = 0.22) for the short-duration and long-duration antibiotic groups. A slightly lower complication rate, including the incidence of abdominal distention (p = 0.093) and antibiotic-associated diarrhea (p = 0.024), was noted in patients with short-duration antibiotic administration. Furthermore, no significant difference in readmission requirements (p = 0.14) or hospitalization duration (p = 0.102) was found between the two groups. For OSI following complicated appendicitis, long-term antibiotic administration did not provide a significant benefit.
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Affiliation(s)
- Chengwei Yan
- Department of Pediatric General Surgery, Chongqing University Three Gorges Hospital, Chongqing, People's Republic of China
| | - Jian Cao
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Bailin Chen
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China. .,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Chongqing, People's Republic of China. .,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
| | - Chunbao Guo
- Department of Pediatric General Surgery, Chongqing University Three Gorges Hospital, Chongqing, People's Republic of China. .,Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China. .,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Chongqing, People's Republic of China. .,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
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8
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Haal S, Wielenga MCB, Fockens P, Leseman CA, Ponsioen CY, van Soest EJ, van Wanrooij RLJ, Sieswerda E, Voermans RP. Antibiotic Therapy of 3 Days May Be Sufficient After Biliary Drainage for Acute Cholangitis: A Systematic Review. Dig Dis Sci 2021; 66:4128-4139. [PMID: 33462749 PMCID: PMC8589797 DOI: 10.1007/s10620-020-06820-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/31/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The optimal antibiotic therapy duration for cholangitis is unclear. Guideline recommendations vary between 4 and 14 days after biliary drainage. Clinical observations and some evidence however suggest that shorter antibiotic therapy may be sufficient. OBJECTIVE To compare the effectiveness and safety of short-course therapy of ≤ 3 days with long-course therapy of ≥ 4 days after biliary drainage in cholangitis patients. METHODS We searched the databases PubMed, EMBASE, Cochrane Library, and trial registers for literature up to August 5, 2020. RCTs and observational studies including case series reporting on antibiotic therapy duration for acute cholangitis were eligible for inclusion. Two reviewers independently evaluated study eligibility, extracted data, assessed risk of bias and quality of evidence. A meta-analysis was planned if the included studies were comparable with regard to important study characteristics. Primary outcomes included recurrent cholangitis, subsequent other infection, and mortality. RESULTS We included eight studies with 938 cholangitis patients. Four observational studies enrolled patients treated for ≤ 3 days. Recurrent cholangitis occurred in 0-26.8% of patients treated with short-course therapy, which did not differ from long-course therapy (range 0-21.1%). Subsequent other infection and mortality rates were also comparable. Quality of available evidence was very low. CONCLUSION There is no high-quality evidence available to draw a strong conclusion, but heterogeneous observational studies suggest that antibiotic therapy of ≤ 3 days is sufficient in cholangitis patients with common bile duct stones.
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Affiliation(s)
- Sylke Haal
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Mattheus C. B. Wielenga
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Charlotte A. Leseman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Cyriel Y. Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Ellert J. van Soest
- Department of Gastroenterology, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Roy L. J. van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Elske Sieswerda
- Department of Medical Microbiology and Infection Control, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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9
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Heil EL, Bork JT, Abbo LM, Barlam TF, Cosgrove SE, Davis A, Ha DR, Jenkins TC, Kaye KS, Lewis JS, Ortwine JK, Pogue JM, Spivak ES, Stevens MP, Vaezi L, Tamma PD. Optimizing the Management of Uncomplicated Gram-Negative Bloodstream Infections: Consensus Guidance Using a Modified Delphi Process. Open Forum Infect Dis 2021; 8:ofab434. [PMID: 34738022 PMCID: PMC8561258 DOI: 10.1093/ofid/ofab434] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/19/2021] [Indexed: 12/24/2022] Open
Abstract
Background Guidance on the recommended durations of antibiotic therapy, the use of oral antibiotic therapy, and the need for repeat blood cultures remain incomplete for gram-negative bloodstream infections. We convened a panel of infectious diseases specialists to develop a consensus definition of uncomplicated gram-negative bloodstream infections to assist clinicians with management decisions. Methods Panelists, who were all blinded to the identity of other members of the panel, used a modified Delphi technique to develop a list of statements describing preferred management approaches for uncomplicated gram-negative bloodstream infections. Panelists provided level of agreement and feedback on consensus statements generated and refined them from the first round of open-ended questions through 3 subsequent rounds. Results Thirteen infectious diseases specialists (7 physicians and 6 pharmacists) from across the United States participated in the consensus process. A definition of uncomplicated gram-negative bloodstream infection was developed. Considerations cited by panelists in determining if a bloodstream infection was uncomplicated included host immune status, response to therapy, organism identified, source of the bacteremia, and source control measures. For patients meeting this definition, panelists largely agreed that a duration of therapy of ~7 days, transitioning to oral antibiotic therapy, and forgoing repeat blood cultures, was reasonable. Conclusions In the absence of professional guidelines for the management of uncomplicated gram-negative bloodstream infections, the consensus statements developed by a panel of infectious diseases specialists can provide guidance to practitioners for a common clinical scenario.
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Affiliation(s)
- Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Jacqueline T Bork
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Lilian M Abbo
- Department of Medicine, University of Miami Miller School of Medicine, Jackson Health System, Miami, Florida, USA
| | - Tamar F Barlam
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sara E Cosgrove
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Angelina Davis
- Division of Infectious Diseases, Duke Antimicrobial Stewardship Outreach Network, Durham, North Carolina, USA
| | - David R Ha
- Department of Quality and Patient Safety, Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | | | - Keith S Kaye
- Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James S Lewis
- Department of Pharmacy, Oregon Health and Science University, Portland, Oregon, USA
| | - Jessica K Ortwine
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Emily S Spivak
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael P Stevens
- Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Liza Vaezi
- Department of Pharmacy, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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10
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Perrella A, Giuliani A, De Palma M, Castriconi M, Molino C, Vennarecci G, Antropoli C, Esposito C, Calise F, Frangiosa A. C-reactive protein but not procalcitonin may predict antibiotic response and outcome in infections following major abdominal surgery. Updates Surg 2021; 74:765-771. [PMID: 34699035 PMCID: PMC8546392 DOI: 10.1007/s13304-021-01172-7] [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] [Received: 08/04/2021] [Accepted: 09/16/2021] [Indexed: 02/05/2023]
Abstract
We aimed to evaluate the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) as markers of infection, sepsis and as predictors of antibiotic response after non-emergency major abdominal surgery. We enrolled, from June 2015 to June 2019, all patients who underwent surgery due to abdominal infection (peritoneal abscess, peritonitis) or having sepsis episode after surgical procedures (i.e. hepatectomy, bowel perforation, pancreaticoduodenectomy (PD), segmental resection of the duodenum (SRD) or biliary reconstruction in a Tertiary Care Hospital. Serum CRP (cut-off value < 5 mg/L) and PCT (cut-off value < 0.1mcg/L) were measured in the day when fever was present or within 24 h after abdominal surgery. Both markers were assessed every 48 h to follow-up antibiotic response and disease evolution up to disease resolution. We enrolled a total of 260 patients underwent non-emergency major abdominal surgery and being infected or developing infection after surgical procedure with one or more microbes (55% mixed Gram-negative infection including Klebsiella KPC, 35% Gram-positive infection, 10% with Candida infection), 58% of patients had ICU admission for at least 96 h, 42% of patients had fast track ICU (48 h). In our group of patients, we found that PCT had a trend to increase after surgical procedure; particularly, those undergoing liver surgery had higher PCT than those underwent different abdominal surgery (U Mann–Whitney p < 0.05). CRP rapidly increase after surgery in those developing infection and showed a statistical significant decrease within 48 h in those subject being responsive to antibiotic treatment and having a clinical response within 10 days independently form the pathogens (bacterial or fungal). Further we found that those having CRP higher than 250 mg/L had a reduced percentage of success treatment at 10 days compared to those < 250 mg/mL (U Mann–Whitney p < 0.05). PCT did not show any variation according to treatment response. CRP in our cohort seems to be a useful marker to predict antibiotic response in those undergoing non-emergency abdominal surgery, while PCT seem to be increased in those having major liver surgery, probably due to hepatic production of cytokines.
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Affiliation(s)
- A Perrella
- Infectious Disease Service at Health Direction Hospital A. Cardarelli, Naples, Italy.
| | - A Giuliani
- Hepatobiliary Surgery and Liver Transplant Center Hospital A. Cardarelli, Naples, Italy.,Surgical Unit, San Carlo Hospital, Potenza, Italy
| | - M De Palma
- General Surgery Hospital A. Cardarelli, Naples, Italy
| | - M Castriconi
- Emergency Surgery Hospital A. Cardarelli, Naples, Italy
| | - C Molino
- I Surgical Unit Hospital A. Cardarelli, Naples, Italy
| | - G Vennarecci
- Hepatobiliary Surgery and Liver Transplant Center Hospital A. Cardarelli, Naples, Italy
| | - C Antropoli
- III Surgical Unit Hospital A. Cardarelli, Naples, Italy
| | - C Esposito
- Liver Intensive Care Unit Hospital A. Cardarelli, Naples, Italy
| | - F Calise
- Surgical Unit Pineta Grande Hospital, Caserta, Italy
| | - A Frangiosa
- Intensive Care Unit Hospital A. Cardarelli, Naples, Italy
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11
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Pan J, Zhu Q, Zhang X, Xu J, Pan L, Mao X, Wu X. Factors Influencing the Prognosis of Patients with Intra-Abdominal Infection and Its Value in Assessing Prognosis. Infect Drug Resist 2021; 14:3425-3432. [PMID: 34466008 PMCID: PMC8402985 DOI: 10.2147/idr.s325386] [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] [Received: 06/18/2021] [Accepted: 08/17/2021] [Indexed: 01/08/2023] Open
Abstract
Purpose To explore the distribution of pathogenic bacteria in patients with intra-abdominal infection, to clarify the independent factors that affect the prognosis of patients with intra-abdominal infection and its evaluation value for prognosis. Patients and Methods The pathogens, underlying diseases, and related clinical data of patients with intra-abdominal infection from January 2012 to December 2019 in our hospital were retrospectively collected and the APACHE II score was calculated. The patients were divided into survival group and death group according to the prognosis, and the index between the two groups was compared. Spearman correlation analysis was used to evaluate the correlation between each index and prognosis, multivariate logistic regression analysis was used to screen the independent prognostic factors. Results Spearman correlation analysis showed that ALB level was negatively correlated with prognosis, age and APACHE II score were positively correlated with prognosis. Logistic regression analysis showed that age, ALB level, and APACHE II score were independent prognostic factors. The formula of age combined ALB level and APACHE II score was Y = X1-3.6X2 + 6.5X3 (X1 was the age, X2 was the ALB level and X3 was the APACHE II score), Y was positively correlated with poor prognosis, and the optimal cutoff value was Y = 40.96. Conclusion Age, ALB level, and APACHE II score are independent factors that influencing the prognosis of patients with intra-abdominal infection, and the combination of age, ALB level, and APACHE II score can better assess the prognosis of patients with intra-abdominal infection.
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Affiliation(s)
- Jianfei Pan
- Department of Emergency, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Quanwei Zhu
- Department of Emergency, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Xiaoqian Zhang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Jun Xu
- Department of Emergency, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Linlin Pan
- Department of Emergency, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Xiang Mao
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Xiao Wu
- Department of Emergency, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China.,Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, 210009, People's Republic of China
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12
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Liu S, Li Y, She F, Zhao X, Yao Y. Predictive value of immune cell counts and neutrophil-to-lymphocyte ratio for 28-day mortality in patients with sepsis caused by intra-abdominal infection. BURNS & TRAUMA 2021; 9:tkaa040. [PMID: 33768121 PMCID: PMC7982795 DOI: 10.1093/burnst/tkaa040] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/16/2020] [Indexed: 12/16/2022]
Abstract
Background The current study aimed to evaluate the value of immune cell counts and neutrophil-to-lymphocyte ratio (NLR) when attempting to predict 28-day mortality. Methods We conducted an observational retrospective study that included consecutive septic patients. Severity scores on the first day and peripheral circulating immune cell counts (at day 1, day 3, day 5 and day 7 of admission) were collected during each patient’s emergency intensive care unit stay. We assessed the associations of peripheral circulating immune cell counts and NLR with the severity of illness. The relationships between 28-day mortality and peripheral circulating immune cell counts and NLR with were evaluated using Cox proportional cause-specific hazards models. Results A total of 216 patients diagnosed with sepsis caused by IAI were enrolled. The lymphocyte counts (days 1, 3, 5 and 7) and monocyte counts (days 3, 5 and 7) were significantly lower in non-survivors (n = 72) than survivors (n = 144). The NLR values at each time point were significantly higher in non-survivors. The day 1 lymphocyte counts, as well as the monocyte counts, were significantly lower in the highest-scoring group, when stratified by the Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, than in the other groups (p < 0.05). The day 1 NLR was significantly higher in the highest-scoring group than in the other groups (p < 0.05). The day 5 and day 7 lymphocyte counts, day 3 and day 7 monocyte counts and day 7 NLR were significant predictors of 28-day mortality in the Cox proportional hazards models (day 5 lymphocyte count: hazard ratio, 0.123 (95% CI, 0.055–0.279), p < 0.001; day 7 lymphocyte count: hazard ratio, 0.115 (95% CI, 0.052–0.254), p < 0.001; day 3 monocyte count: hazard ratio, 0.067 (95% CI, 0.005–0.861), p = 0.038; day 7 monocyte count: hazard ratio, 0.015 (95% CI, 0.001–0.158), p < 0.001; day 7 NLR: hazard ratio, 0.773 (95% CI, 0.659–0.905), p = 0.001). Conclusions The results showed that circulating lymphocytes and monocytes were dramatically decreased within 7 days in non-survivors following sepsis from an IAI. Lymphocyte counts, monocyte counts and NLR appeared to be associated with the severity of illness, and they may serve as independent predictors of 28-day mortality in septic patients with IAIs.
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Affiliation(s)
- Shuangqing Liu
- Medical school of Chinese PLA, No. 28 Fuxing Road, Haidian District, Beijing 100853, China.,Department of Emergency, the Fourth Medical Center of the Chinese PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing 100048, China.,Trauma Research Center, the Fourth Medical Center of the Chinese PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing 100048, China
| | - Yuxuan Li
- Medical school of Chinese PLA, No. 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Fei She
- Department of Emergency, the Fourth Medical Center of the Chinese PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing 100048, China
| | - Xiaodong Zhao
- Department of Emergency, the Fourth Medical Center of the Chinese PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing 100048, China
| | - Yongming Yao
- Medical school of Chinese PLA, No. 28 Fuxing Road, Haidian District, Beijing 100853, China.,Trauma Research Center, the Fourth Medical Center of the Chinese PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing 100048, China
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13
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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14
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Liu J, Zhang L, Pan J, Huang M, Li Y, Zhang H, Wang R, Zhao M, Li B, Liu L, Gong Y, Bian J, Li X, Tang Y, Lei M, Chen D. Risk Factors and Molecular Epidemiology of Complicated Intra-Abdominal Infections With Carbapenem-Resistant Enterobacteriaceae: A Multicenter Study in China. J Infect Dis 2021; 221:S156-S163. [PMID: 32176797 DOI: 10.1093/infdis/jiz574] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) infections are associated with poor patient outcomes. Data on risk factors and molecular epidemiology of CRE in complicated intra-abdominal infections (cIAI) in China are limited. This study examined the risk factors of cIAI with CRE and the associated mortality based on carbapenem resistance mechanisms. METHODS In this retrospective analysis, we identified 1024 cIAI patients hospitalized from January 1, 2013 to October 31, 2018 in 14 intensive care units in China. Thirty CRE isolates were genotyped to identify β-lactamase-encoding genes. RESULTS Escherichia coli (34.5%) and Klebsiella pneumoniae (21.2%) were the leading pathogens. Patients with hospital-acquired cIAI had a lower rate of E coli (26.0% vs 49.1%; P < .001) and higher rate of carbapenem-resistant Gram-negative bacteria (31.7% vs 18.8%; P = .002) than those with community-acquired cIAI. Of the isolates, 16.0% and 23.4% of Enterobacteriaceae and K pneumoniae, respectively, were resistant to carbapenem. Most carbapenemase-producing (CP)-CRE isolates carried blaKPC (80.9%), followed by blaNMD (19.1%). The 28-day mortality was 31.1% and 9.0% in patients with CRE vs non-CRE (P < .001). In-hospital mortality was 4.7-fold higher for CP-CRE vs non-CP-CRE infection (P = .049). Carbapenem-containing combinations did not significantly influence in-hospital mortality of CP and non-CP-CRE. The risk factors for 28-day mortality in CRE-cIAI included septic shock, antibiotic exposure during the preceding 30 days, and comorbidities. CONCLUSIONS Klebsiella pneumoniae had the highest prevalence in CRE. Infection with CRE, especially CP-CRE, was associated with increased mortality in cIAI.
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Affiliation(s)
- Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lidi Zhang
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingye Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical School, Wenzhou, Zhejiang, China
| | - Man Huang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yingchuan Li
- Department of Critical Care Medicine, Shanghai the Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hongjin Zhang
- Department of Critical Care Medicine, Dongyang People's Hospital, Dongyang, Zhejiang, China
| | - Ruilan Wang
- Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mingyan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjing, China
| | - Bin Li
- Department of Critical Care Medicine, the First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Long Liu
- Intensive Care Unit, The First People's Hospital of Kunshan, Kunshan, Jiangsu, China
| | - Ye Gong
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jinjun Bian
- Department of Critical Care Medicine, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Xiang Li
- Department of Critical Care Medicine, Minhang Hospital, Fudan University, Shanghai, China
| | - Yan Tang
- Department of Critical Care Medicine, Qingpu Branch of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming Lei
- Department of Critical Care Medicine, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Badia JM, Batlle M, Juvany M, Ruiz-de León P, Sagalés M, Pulido MA, Molist G, Cuquet J. Surgeon-led 7-VINCut Antibiotic Stewardship Intervention Decreases Duration of Treatment and Carbapenem Use in a General Surgery Service. Antibiotics (Basel) 2020; 10:antibiotics10010011. [PMID: 33374393 PMCID: PMC7823351 DOI: 10.3390/antibiotics10010011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/16/2020] [Accepted: 12/23/2020] [Indexed: 12/13/2022] Open
Abstract
Antibiotic stewardship programs optimize the use of antimicrobials to prevent the development of resistance and improve patient outcomes. In this prospective interventional study, a multidisciplinary team led by surgeons implemented a program aimed at shortening the duration of antibiotic treatment <7 days. The impact of the intervention on antibiotic consumption adjusted to bed-days and discharges, and the isolation of multiresistant bacteria (MRB) was also studied. Furthermore, the surgeons were surveyed regarding their beliefs and feelings about the program. Out of 1409 patients, 40.7% received antibiotic therapy. Treatment continued for over 7 days in 21.5% of cases, and, as can be expected, source control was achieved in only 48.8% of these cases. The recommendations were followed in 90.2% of cases, the most frequent being to withdraw the treatment (55.6%). During the first 16 months of the intervention, a sharp decrease in the percentage of extended treatments, with R2 = 0.111 was observed. The program was very well accepted by surgeons, and achieved a decrease in both the consumption of carbapenems and in the number of MRB isolations. Multidisciplinary stewardship teams led by surgeons seem to be well received and able to better manage antibiotic prescription in surgery.
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Affiliation(s)
- Josep M. Badia
- Department of Surgery, Hospital General Granollers, Universitat Internacional de Catalunya, 08402 Granollers, Spain; (M.B.); (M.J.); (P.R.-d.L.)
- Correspondence: or ; Tel.: +34-670702099
| | - Maria Batlle
- Department of Surgery, Hospital General Granollers, Universitat Internacional de Catalunya, 08402 Granollers, Spain; (M.B.); (M.J.); (P.R.-d.L.)
| | - Montserrat Juvany
- Department of Surgery, Hospital General Granollers, Universitat Internacional de Catalunya, 08402 Granollers, Spain; (M.B.); (M.J.); (P.R.-d.L.)
| | - Patricia Ruiz-de León
- Department of Surgery, Hospital General Granollers, Universitat Internacional de Catalunya, 08402 Granollers, Spain; (M.B.); (M.J.); (P.R.-d.L.)
| | - Maria Sagalés
- Department of Clinical Pharmacy, Hospital General Granollers, 08402 Granollers, Spain;
| | - M Angeles Pulido
- Department of Clinical Microbiology, Hospital General Granollers, 08402 Granollers, Spain;
| | - Gemma Molist
- Department of Statistics and Research, Hospital General Granollers, 08402 Granollers, Spain;
| | - Jordi Cuquet
- Infectious Diseases Unit, Hospital General Granollers, 08402 Granollers, Spain;
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Simó S, Velasco-Arnaiz E, Ríos-Barnés M, López-Ramos MG, Monsonís M, Urrea-Ayala M, Jordan I, Casadevall-Llandrich R, Ormazábal-Kirchner D, Cuadras-Pallejà D, Tarrado X, Prat J, Sánchez E, Noguera-Julian A, Fortuny C. Effects of a Paediatric Antimicrobial Stewardship Program on Antimicrobial Use and Quality of Prescriptions in Patients with Appendix-Related Intraabdominal Infections. Antibiotics (Basel) 2020; 10:antibiotics10010005. [PMID: 33374676 PMCID: PMC7822420 DOI: 10.3390/antibiotics10010005] [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] [Received: 11/27/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 11/16/2022] Open
Abstract
The effectiveness of antimicrobial stewardship programs (ASP) in reducing antimicrobial use (AU) in children has been proved. Many interventions have been described suitable for different institution sizes, priorities, and patients, with surgical wards being one of the areas that may benefit the most. We aimed to describe the results on AU and length of stay (LOS) in a pre-post study during the three years before (2014–2016) and the three years after (2017–2019) implementation of an ASP based on postprescription review with feedback in children and adolescents admitted for appendix-related intraabdominal infections (AR-IAI) in a European Referral Paediatric University Hospital. In the postintervention period, the quality of prescriptions (QP) was also evaluated. Overall, 2021 AR-IAIs admissions were included. Global AU, measured both as days of therapy/100 patient days (DOT/100PD) and length of therapy (LOT), and global LOS remained unchanged in the postintervention period. Phlegmonous appendicitis LOS (p = 0.003) and LOT (p < 0.001) significantly decreased, but not those of other AR-IAI diagnoses. The use of piperacillin–tazobactam decreased by 96% (p = 0.044), with no rebound in the use of other Gram-negative broad-spectrum antimicrobials. A quasisignificant (p = 0.052) increase in QP was observed upon ASP implementation. Readmission and case fatality rates remained stable. ASP interventions were safe, and they reduced LOS and LOT of phlegmonous appendicitis and the use of selected broad-spectrum antimicrobials, while increasing QP in children with AR-IAI.
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Affiliation(s)
- Sílvia Simó
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
| | - Eneritz Velasco-Arnaiz
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
| | - María Ríos-Barnés
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
| | | | - Manuel Monsonís
- Clinical Microbiology Department, Sant Joan de Déu Hospital, 08950 Barcelona, Spain;
| | - Mireia Urrea-Ayala
- Patient Safety Area—Infection Control Unit, Sant Joan de Déu Hospital, 08950 Barcelona, Spain;
| | - Iolanda Jordan
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
- Pediatric Intensive Care Unit, Sant Joan de Déu Hospital, 08950 Barcelona, Spain
- Department of Paediatrics, University of Barcelona, 08007 Barcelona, Spain
| | | | | | | | - Xavier Tarrado
- Paediatric Surgery Department, Sant Joan de Déu Hospital, 08950 Barcelona, Spain; (X.T.); (J.P.)
| | - Jordi Prat
- Paediatric Surgery Department, Sant Joan de Déu Hospital, 08950 Barcelona, Spain; (X.T.); (J.P.)
| | - Emília Sánchez
- Blanquerna School of Health Science, Ramon Llull University, 08022 Barcelona, Spain;
| | - Antoni Noguera-Julian
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
- Statistics Department, Sant Joan de Déu Research Foundation, 08950 Barcelona, Spain;
- Translational Research Network in Paediatric Infectious Diseases (RITIP), 28009 Madrid, Spain
- Correspondence: ; Tel.: +34-932-804-000 (ext. 80063); Fax: +34-932-033-959
| | - Clàudia Fortuny
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
- Statistics Department, Sant Joan de Déu Research Foundation, 08950 Barcelona, Spain;
- Translational Research Network in Paediatric Infectious Diseases (RITIP), 28009 Madrid, Spain
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Patel K, Maguigan KL, Loftus TJ, Mohr AM, Shoulders BR. Optimal Antibiotic Duration for Bloodstream Infections Secondary to Intraabdominal Infection. J Surg Res 2020; 260:82-87. [PMID: 33326932 DOI: 10.1016/j.jss.2020.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/06/2020] [Accepted: 10/31/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Bloodstream infections (BSIs) secondary to intraabdominal infections (IAIs) are common in the intensive care unit (ICU). The Surgical Infection Society guidelines recommend treatment duration after achieving source control in patients with secondary bacteremia; however, literature supporting this recommendation is limited. The purpose of this study was to compare outcomes in patients who received shorter versus extended duration of antibiotics for bacteremia secondary to IAI. MATERIALS AND METHODS A retrospective cohort analysis was conducted in adult surgical ICU patients (n = 42) with BSIs and source control procedure(s) for IAI. The primary outcome was recurrent IAI. Secondary outcomes included surgical site infections (SSIs), Clostridium difficile infections (CDIs), secondary fungal infections, and in-hospital mortality. RESULTS Forty-two patients met inclusion criteria and were divided into groups according to antimicrobial duration; 12 patients received <7 d, and 30 patients received >7 d of antibiotics. There were no differences in baseline characteristics between the two cohorts except for the presence of sepsis [4/12 (33.3%) versus 27/30 (90.0%); P = 0.001]. Thirty-one percent (13/42) of all organisms isolated from blood cultures were gram-negative bacteria, 12/42 (28.6%) were MDROs, and 2/42 (4.8%) patients experienced a culture mismatch in which cultured bacteria were not susceptible to empiric antibiotic therapy. Rates of recurrent IAI were similar between the two cohorts [1/12 (8.3%) versus 4/30 (13.3%), P = 0.554]. CONCLUSIONS Among surgical ICU patients with BSI secondary to IAI, cessation of antibiotic therapy within 7 d of source control was not associated with an increased incidence of recurrent IAI.
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Affiliation(s)
- Khushboo Patel
- Department of Pharmacy, Vidant Medical Center, Greenville, North Carolina
| | - Kelly L Maguigan
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, Florida
| | - Tyler J Loftus
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Alicia M Mohr
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Bethany R Shoulders
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida.
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18
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Mele TS, Kaafarani HMA, Guidry CA, Loor MM, Machado-Aranda D, Mendoza AE, Morris-Stiff G, Rattan R, Schubl SD, Barie PS. Surgical Infection Society Research Priorities: A Narrative Review of Fourteen Years of Progress. Surg Infect (Larchmt) 2020; 22:568-582. [PMID: 33275862 DOI: 10.1089/sur.2020.309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: In 2006, the Surgical Infection Society (SIS) utilized a modified Delphi approach to define 15 specific priority research questions that remained unanswered in the field of surgical infections. The aim of the current study was to evaluate the scientific progress achieved during the ensuing period in answering each of the 15 research questions and to determine if additional research in these fields is warranted. Methods: For each of the questions, a literature search using the National Center for Biotechnology Information (NCBI) was performed by the Scientific Studies Committee of the SIS to identify studies that attempted to address each of the defined questions. This literature was analyzed and summarized. The data on each question were evaluated by a surgical infections expert to determine if the question was answered definitively or remains unanswered. Results: All 15 priority research questions were studied in the last 14 years; six questions (40%) were definitively answered and 9 questions (60%) remain unanswered in whole or in part, mainly because of the low quality of the studies available on this topic. Several of the 9 unanswered questions were deemed to remain research priorities in 2020 and warrant further investigation. These included, for example, the role of empiric antimicrobial agents in nosocomial infections, the use of inotropes/vasopressors versus volume loading to raise the mean arterial pressure, and the role of increased antimicrobial dosing and frequency in the obese patient. Conclusions: Several surgical infection-related research questions prioritized in 2006 remain unanswered. Further high-quality research is required to provide a definitive answer to many of these priority knowledge gaps. An updated research agenda by the SIS is warranted at this time to define research priorities for the future.
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Affiliation(s)
- Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher A Guidry
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michele M Loor
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Machado-Aranda
- Division of Acute Care Surgery, Michigan Medicine and Ann Arbor Veterans' Affairs Health System, Ann Arbor, Michigan, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gareth Morris-Stiff
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rishi Rattan
- Division of Trauma Surgery and Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine, California, USA
| | - Philip S Barie
- Division of Trauma Burns, Acute and Critical Care, Department of Surgery, and Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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DeCesare L, Xu TQ, Saclarides C, Coughlin JM, Chivukula SV, Woodfin A, Chan E, Booker C, Jacobson R. Trends in Antibiotic Duration for Complicated Intra-Abdominal Infections : Adaptation to Current Guidelines. Am Surg 2020; 87:120-124. [PMID: 32845728 DOI: 10.1177/0003134820942186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The 2017 surgical infection society (SIS) guidelines recommend 4 days of antibiotic therapy after source control for complicated intra-abdominal infections (cIAIs). Inappropriate exposure to antibiotics has a negative impact on outcomes in individual patients and populations. The goal of this study was to evaluate our institution's practice patterns and adherence to current antibiotic guidelines. METHODS Medical records from 2010 to 2018 for cIAIs were examined. Complicated appendicitis and complicated diverticulitis cases were included. Exclusion criteria included other etiologies of IAIs, pediatric cases, and cancer operations. RESULTS Fifty-nine complicated appendicitis cases and 96 complicated diverticulitis cases were identified. For all cases, antibiotic duration prior to publication of the SIS guidelines was significantly longer than post-SIS duration (appendicitis: 12.6 ± 1.1 days pre-SIS [n = 37] vs 9.0 ± 1.1 days post-SIS [n = 22], P = .01; diverticulitis: 15.1 ± 0.8 days pre-SIS [n = 49] vs 11.2 ± 0.5 post-SIS [n = 47], P = .04). Surgical management (SM) was associated with shorter duration of postsource control antibiotic exposure compared with percutaneous drainage (PD) for both appendicitis (SM 10.0 ± 1.2 days vs PD 13.4 ± 1.0 days, P = .02) and diverticulitis (SM 12.8 ± 1.5 days vs PD 16.0 ± 1.5, P = .07). Patients with complicated appendicitis received shorter duration of antibiotics when managed by acute care surgeons compared to general surgeons (8.4 ± 1.1 vs 11.9 ± 0.8, P = .02). CONCLUSION Despite improvements after the SIS guidelines' publication, the antibiotic duration is still longer than recommended. Surgical intervention and management by acute care specialists were associated with a shorter duration of antibiotic exposure.
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Affiliation(s)
- Laura DeCesare
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Thomas Q Xu
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Julia M Coughlin
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Ashley Woodfin
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Edie Chan
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Connor Booker
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Richard Jacobson
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
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20
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Borges I, Carneiro R, Bergo R, Martins L, Colosimo E, Oliveira C, Saturnino S, Andrade MV, Ravetti C, Nobre V. Duration of antibiotic therapy in critically ill patients: a randomized controlled trial of a clinical and C-reactive protein-based protocol versus an evidence-based best practice strategy without biomarkers. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:281. [PMID: 32487263 PMCID: PMC7266125 DOI: 10.1186/s13054-020-02946-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/05/2020] [Indexed: 12/16/2022]
Abstract
Background The rational use of antibiotics is one of the main strategies to limit the development of bacterial resistance. We therefore sought to evaluate the effectiveness of a C-reactive protein-based protocol in reducing antibiotic treatment time in critically ill patients. Methods A randomized, open-label, controlled clinical trial conducted in two intensive care units of a university hospital in Brazil. Critically ill infected adult patients were randomly allocated to (i) intervention to receive antibiotics guided by daily monitoring of CRP levels and (ii) control to receive antibiotics according to the best practices for rational use of antibiotics. Results One hundred thirty patients were included in the CRP (n = 64) and control (n = 66) groups. In the intention-to-treat analysis, the median duration of antibiotic therapy for the index infectious episode was 7.0 (5.0–8.8) days in the CRP and 7.0 (7.0–11.3) days in the control (p = 0.011) groups. A significant difference in the treatment time between the two groups was identified in the curve of cumulative suspension of antibiotics, with less exposure in the CRP group only for the index infection episode (p = 0.007). In the per protocol analysis, involving 59 patients in each group, the median duration of antibiotic treatment was 6.0 (5.0–8.0) days for the CRP and 7.0 (7.0–10.0) days for the control (p = 0.011) groups. There was no between-group difference regarding the total days of antibiotic exposure and antibiotic-free days. Conclusions Daily monitoring of CRP levels may allow early interruption of antibiotic therapy in a higher proportion of patients, without an effect on total antibiotic consumption. The clinical and microbiological relevance of this finding remains to be demonstrated. Trial registry ClinicalTrials.gov Identifier: NCT02987790. Registered 09 December 2016.
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Affiliation(s)
- Isabela Borges
- Graduate Program in Health Sciences: Infectious Diseases and Tropical Medicine, Department of Internal Medicine, School of Medicine and Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil. .,Departamento de Clínica Médica, 2° andar Faculdade de Medicina. Av. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, Minas Gerais, Brazil.
| | - Rafael Carneiro
- Graduate Program in Health Sciences: Infectious Diseases and Tropical Medicine, Department of Internal Medicine, School of Medicine and Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Rafael Bergo
- Graduate Program in Health Sciences: Infectious Diseases and Tropical Medicine, Department of Internal Medicine, School of Medicine and Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Larissa Martins
- Graduate Program in Statistics, Department of Statistics, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Enrico Colosimo
- Graduate Program in Statistics, Department of Statistics, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Carolina Oliveira
- Graduate Program in Health Sciences: Adult Health, Department of Internal Medicine, School of Medicine and Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Saulo Saturnino
- Graduate Program in Health Sciences: Adult Health, Department of Internal Medicine, School of Medicine and Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Marcus Vinícius Andrade
- Graduate Program in Health Sciences: Adult Health, Department of Internal Medicine, School of Medicine and Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Cecilia Ravetti
- Graduate Program in Health Sciences: Infectious Diseases and Tropical Medicine, Department of Internal Medicine, School of Medicine and Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Vandack Nobre
- Graduate Program in Health Sciences: Infectious Diseases and Tropical Medicine, Department of Internal Medicine, School of Medicine and Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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21
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Twenty-four hour versus extended antibiotic administration after surgery in complicated appendicitis: A randomized controlled trial. J Trauma Acute Care Surg 2020; 86:36-42. [PMID: 30308538 DOI: 10.1097/ta.0000000000002086] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent investigations noted noninferiority in short-course antimicrobial treatments following source control in abdominal infections. We set out to investigate noninferiority of a short and fixed (24 hours) antibiotic administration compared to extended treatment after source control in complicated appendicitis in a prospective single-center open-label randomized controlled trial. METHODS After Institutional Review Board (IRB) approval, all consecutive adult patients (age, ≥ 18 years) with complicated appendicitis including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between May 2016 and February 2018 were randomly allocated to antibacterial therapy limited to 24 hours (short) vs. >24 hours (extended) administration after appendectomy. Primary outcomes included composite postoperative complications and Comprehensive Complication Index (CCI). Secondary outcome was hospital length of stay (HLOS). Follow-up analysis at 1 month was conducted per intention and per protocol. RESULTS A total of 80 patients were enrolled with 39 and 41 cases allocated to the short and the extended therapy group, respectively. Demographic profile and disease severity was similar between the study groups. Overall rate of complications was 17.9% and 29.3% in the short and extended group, respectively (p = 0.23). Mean CCI did not differ between the study groups (p = 0.29). Hospital length of stay was significantly reduced in the short therapy group (61 ± 34 hours vs. 81 ± 40 hours, p = 0.005). CONCLUSION In the current prospective randomized investigation, the short (24 hours) antibiotic administration following appendectomy did not result in a worse primary outcome in complicated appendicitis. The short interval administration resulted in a significant reduction in HLOS with a major cost-saving and antibacterial stewardship perspective. LEVEL OF EVIDENCE Therapeutic Level IV.
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22
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Haal S, Ten Böhmer B, Balkema S, Depla AC, Fockens P, Jansen JM, Kuiken SD, Liberov BI, van Soest E, van Hooft JE, Sieswerda E, Voermans RP. Antimicrobial therapy of 3 days or less is sufficient after successful ERCP for acute cholangitis. United European Gastroenterol J 2020; 8:481-488. [PMID: 32213042 PMCID: PMC7226689 DOI: 10.1177/2050640620915016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Recommendations for the duration of antimicrobial therapy in cholangitis
after successful endoscopic biliary drainage vary. The aim of this study was
to compare the occurrence of local infectious complications in patients with
acute cholangitis treated with antibiotics for 3 days or less compared with
4 days or more. Methods We performed a retrospective multicentre study in seven hospitals in the
Netherlands. Patients who received a successful biliary drainage by
endoscopic retrograde cholangio-pancreatography because of cholangitis due
to common bile duct stones between 2012 and 2017 were included. The primary
outcome was the occurrence of a local infectious complication within 3
months of endoscopic retrograde cholangio-pancreatography. Secondary
outcomes included Clostridioides difficile infection, total
length of hospital stay and all-cause mortality. Results A total of 426 patients with cholangitis were identified and 296 patients met
all inclusion criteria. Therapy duration was ≤3 days in 137 patients
(46.3%). During follow-up, 41 patients (13.9%) developed a local infectious
complication. Occurrence of infectious complications did not differ between
the two groups (p = 0.32). No patient developed
Clostridioides difficile infection. Median hospital
stay was 6 days (interquartile range 4–8 days) in the short antibiotic group
compared with 7 days (interquartile range 5–9 days) in the long group
(p = 0.03). Four (1.4%) patients died during follow-up,
all were treated for ≥4 days
(p = 0.13). Conclusions Antimicrobial therapy of 3 days or less seems to be sufficient after
successful biliary drainage in patients with acute cholangitis. Randomized
trials should confirm our findings.
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Affiliation(s)
- Sylke Haal
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam, Netherlands.,Department of Internal medicine, Spaarne Gasthuis, Hoofddorp, Netherlands
| | - Britt Ten Böhmer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam, Netherlands
| | - Sebastiaan Balkema
- Department of Gastroenterology, Dijklander Ziekenhuis, Hoorn, Netherlands
| | | | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, Netherlands
| | - Boris I Liberov
- Department of Internal medicine, Zaans Medisch Centrum, Zaandam, Netherlands
| | - Ellert van Soest
- Department of Gastroenterology, Spaarne Gasthuis, Hoofddorp, Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam, Netherlands
| | - Elske Sieswerda
- Department of Medical Microbiology and Infection Control, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam, Netherlands
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23
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Liu Q, Hao F, Chen B, Li L, Liu Q, Guo C. Multi-Center Prospective Study of Restrictive Post-Operative Antibiotic Treatment of Children with Complicated Appendicitis. Surg Infect (Larchmt) 2020; 21:778-783. [PMID: 32150521 DOI: 10.1089/sur.2019.293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: No consensus has been reached regarding the most advantageous duration of antibiotic prophylaxis to decrease post-operative infection complications of appendectomy for acute complex appendicitis. This study aimed to determine the efficacy of short-term antibiotic treatment on post-operative complications in children with complex appendicitis. Methods: A multi-center, parallel group, randomized study was conducted in patients younger than 14 years of age with complicated appendicitis at three hospitals in China. The qualified patients were randomized prospectively to either the restrictive 72-hour short-term antibiotic strategy or the standard antibiotic usage. A comparison of the complications within 24 months, including infectious complications and long-term results, were conducted between the two groups. This trial is registered with the Chinese Clinical Trial Registry (ChiCTR), number ChiCTR1900023941 and is complete. Results: A shorter duration of antibiotic treatment had no effect on intestinal function recovery, antibiotic-associated diarrhea, and health-care-associated Clostridium difficile infection and infectious complication, including intra-abdominal abscess development (17.9% vs. 18.0%, p = 0.52). Furthermore, no substantial difference for re-admission requirement and re-operation were found between the two treatment strategies. A sizeable decrease in total duration of hospitalization (p < 0.001) and average total antibiotic duration (p < 0.001) were observed for the restrictive antibiotic strategy group. Conclusion: In complicated appendicitis, the restrictive antibiotic usage was equivalent to standard antibiotic usage in terms of short- and long-term outcomes, but with shorter hospital stays and fewer antibiotic agents.
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Affiliation(s)
- Qianyang Liu
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Fabao Hao
- Department of Pediatric General Surgery, Qingdao Maternity and Child Care Hospital, Qingdao, P.R. China
| | - Bailin Chen
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Lei Li
- Department of Neonatology, Jinan Maternity and Child Care Hospital, Jinan, P.R. China
| | - Qingshuang Liu
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Chunbao Guo
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China.,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
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24
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Robbins SN, Goggs R, Lhermie G, Lalonde-Paul DF, Menard J. Antimicrobial Prescribing Practices in Small Animal Emergency and Critical Care. Front Vet Sci 2020; 7:110. [PMID: 32258067 PMCID: PMC7093014 DOI: 10.3389/fvets.2020.00110] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/13/2020] [Indexed: 01/30/2023] Open
Abstract
Background: Antimicrobial use contributes to emergence of antimicrobial resistance. It was hypothesized that antimicrobial prescribing behavior varies between the emergency (ER) and critical care (CC) services in a veterinary teaching hospital. This study aimed to: (i) describe antimicrobial prescribing patterns in the ER and CC services; (ii) assess adherence to stewardship principles; (iii) evaluate the prevalence of multidrug resistant (MDR) bacterial isolates. Methods: Institution electronic medical records were queried for all antimicrobial prescriptions from the ER and CC services between 1/1/2017 and 12/31/2017. Prescriptions were manually reviewed, and the following data recorded: drug, dosage, duration, diagnosis, outcome, hospitalization duration, culture submission, and susceptibility results. Results: There were 5,091 ER visits, of which 3,125 were not transferred to another service. Of these emergency visits, 516 (16.5%) resulted in 613 antimicrobial drug prescriptions. The most commonly prescribed drugs for the ER were amoxicillin/clavulanate (n = 243, 39.6%), metronidazole (n = 146, 23.8%), and ampicillin/sulbactam (n = 55, 9.0%). The most common reasons for antimicrobial prescriptions were skin disease (n = 227, 37.0%), gastrointestinal disease (n = 173, 28.2%), and respiratory disease (n = 50, 8.2%). For ER patients 18 cultures were submitted, equivalent to a 3.5% submission rate. The CC service managed 311 case visits for 822 patient days. Of these, 133 case visits (42.7%) resulted in 340 prescriptions. The most commonly prescribed drugs for the CC service were ampicillin/sulbactam (n = 103, 30.3%), enrofloxacin (n = 75, 22.1%), and metronidazole (n = 59, 17.4%). The most common reasons for antimicrobial prescriptions were gastrointestinal disease (n = 106, 31.2%), respiratory disease (n = 71, 20.9%), and sepsis (n = 61, 17.9%). On the CC service, 46 patients had ≥1 culture submitted, equivalent to a 34.6% submission rate. Of patients prescribed antimicrobials, 13/38 (34%) with urinary tract disease, 2/28 (7%) with pneumonia, 1/11 (9%) with canine infectious respiratory disease complex and 2/8 (25%) with feline upper respiratory infection were compliant with published guidelines. Conclusions: Antimicrobial prescription was common in both ER and CC services and followed similar patterns. Adherence to published guidelines for urinary and respiratory infections was poor.
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Affiliation(s)
- Sarah N Robbins
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Robert Goggs
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Guillaume Lhermie
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States.,IHAP, Université de Toulouse, INRA, ENVT, Toulouse, France
| | - Denise F Lalonde-Paul
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Julie Menard
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
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25
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Ho VP, Kaafarani H, Rattan R, Namias N, Evans H, Zakrison TL. Sepsis 2019: What Surgeons Need to Know. Surg Infect (Larchmt) 2019; 21:195-204. [PMID: 31755816 DOI: 10.1089/sur.2019.126] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The definition of sepsis continues to be as dynamic as the management strategies used to treat this. Sepsis-3 has replaced the earlier systemic inflammatory response syndrome (SIRS)-based diagnoses with the rapid Sequential Organ Failure Assessment (SOFA) score assisting in predicting overall prognosis with regards to mortality. Surgeons have an important role in ensuring adequate source control while recognizing the threat of carbapenem-resistance in gram-negative organisms. Rapid diagnostic tests are being used increasingly for the early identification of multi-drug-resistant organisms (MDROs), with a key emphasis on the multidisciplinary alert of results. Novel, higher generation antibiotic agents have been developed for resistance in ESKCAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) organisms while surgeons have an important role in the prevention of spread. The Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial has challenged the previous paradigm of length of antibiotic treatment whereas biomarkers such as procalcitonin are playing a prominent role in individualizing therapy. Several novel therapies for refractory septic shock, while still investigational, are gaining prominence rapidly (such as vitamin C) whereas others await further clinical trials. Management strategies presented as care bundles continue to be updated by the Surviving Sepsis Campaign, yet still remain controversial in its global adoption. We have broadened our temporal and epidemiologic perspective of sepsis by understanding it both as an acute, time-sensitive, life-threatening illness to a chronic condition that increases the risk of mortality up to five years post-discharge. Artificial intelligence, machine learning, and bedside scoring systems can assist the clinician in predicting post-operative sepsis. The public health role of the surgeon is key. This includes collaboration and multi-disciplinary antibiotic stewardship at a hospital level. It also requires controlling pharmaceutical sales and the unregulated dispensing of antibiotic agents globally through policy initiatives to control emerging resistance through prevention.
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Affiliation(s)
- Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Haytham Kaafarani
- Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Boston, Massachusetts
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, Florida
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, Florida
| | - Heather Evans
- Division of General & Acute Care Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Tanya L Zakrison
- Section for Trauma and Acute Care Surgery, The University of Chicago Medicine, Chicago, Illinois
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26
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Martin-Loeches I, Timsit JF, Leone M, de Waele J, Sartelli M, Kerrigan S, Azevedo LCP, Einav S. Clinical controversies in abdominal sepsis. Insights for critical care settings. J Crit Care 2019; 53:53-58. [DOI: 10.1016/j.jcrc.2019.05.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/27/2022]
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27
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Takesue Y, Uchino M, Ikeuchi H, Ueda T, Nakajima K. Is fixed short-course antimicrobial therapy justified for patients who are critically ill with intra-abdominal infections? J Anus Rectum Colon 2019; 3:53-59. [PMID: 31559368 PMCID: PMC6752122 DOI: 10.23922/jarc.2019-001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/22/2019] [Indexed: 12/29/2022] Open
Abstract
A long-course antibiotic therapy increases the risk of antibiotic resistance. A 7- to 14-day duration of therapy has been traditionally adopted in patients with intra-abdominal infections (IAIs). Prophylactic antibiotic use is warranted in uncomplicated IAIs, in which the infection involves a single organ, and the source of the infection is completely eradicated by a surgical procedure. A large, randomized clinical trial of the treatment of complicated IAIs recently demonstrated that a fixed 4-day course of antibiotic therapy was as effective as a long-course therapy in patients who underwent adequate source control. Considering the poor prognosis and lack of clear evidence available for shortening the duration of antibiotic therapy in patients who are critically ill or those with ongoing signs of sepsis, the duration of therapy for complicated IAIs should be individually determined according to the clinical course. Limiting therapy to no more than 7 days seems to be warranted in patients who are critically ill with a good clinical response.
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Affiliation(s)
- Yoshio Takesue
- Department of Infection Prevention and Control, Hyogo College of Medicine
| | - Motoi Uchino
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine
| | - Takashi Ueda
- Department of Infection Prevention and Control, Hyogo College of Medicine
| | - Kazuhiko Nakajima
- Department of Infection Prevention and Control, Hyogo College of Medicine
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28
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Walker C, Moosavi A, Young K, Fluck M, Torres D, Widom K, Wild J. Factors Associated with Failure of Nonoperative Management for Complicated Appendicitis. Am Surg 2019. [DOI: 10.1177/000313481908500840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In recent years, nonoperative management of complicated appendicitis has become more common. Patients managed nonoperatively do well, but there is a paucity of literature on patients who fail nonoperative management. The purpose of this study was to examine the overall failure rate, morbidity associated with failure, and potential predictors of failure in nonop management of appendicitis. This is a descriptive retrospective review of patients from a single hospital system who were diagnosed with advanced appendicitis and underwent nonop management between January 1, 2007, and November of 2017. The data were obtained through review of patient charts from the electronic medical record. Failure was defined as requirement of an operation due to ongoing infection secondary to appendicitis. There were 183 patients initially managed non-operatively, with 70 patients failing nonoperative management. Patients failing nonoperative management experienced longer hospitalization (6.2 vs 2.9 days, P < 0.0001), and more patients in the failure group required admission to the ICU (10.0% vs 1.8%, P = 0.028). Multivariate analysis revealed that longer duration of symptoms reduced the likelihood of failure (odds ratio: 0.77 [0.64–0.92]). In this retrospective review, 38 per cent of patients failed nonop management of appendicitis. Symptom duration could provide insight for clinicians in assessing the role of non-operative management because increasing symptom duration reduced the likelihood of failure.
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Affiliation(s)
- Charles Walker
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Ali Moosavi
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Katelyn Young
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Marcus Fluck
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Denise Torres
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Kenneth Widom
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Jeffrey Wild
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
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29
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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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30
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Schmoch T, Al-Saeedi M, Hecker A, Richter DC, Brenner T, Hackert T, Weigand MA. Evidenzbasierte, interdisziplinäre Behandlung der abdominellen Sepsis. Chirurg 2019; 90:363-378. [DOI: 10.1007/s00104-019-0795-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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31
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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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32
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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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33
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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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34
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Cancel that PICC line order; cholecystostomy tube and short course of antibiotics. Am J Surg 2018; 217:485-489. [PMID: 30415929 DOI: 10.1016/j.amjsurg.2018.10.044] [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] [Received: 07/23/2018] [Revised: 10/26/2018] [Accepted: 10/26/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Current guidelines do not specifically address optimal antibiotic duration following cholecystostomy. This study compares outcomes for short-course (<7 days) and long-course (≥7 days) antibiotics post-cholecystostomy. METHODS This was a retrospective review of cholecystostomy patients (≥18 years) admitted (1/1/2007-12/31/2017) to one healthcare system. RESULTS Overall, 214 patients were studied. Demographics were similar, except short-course patients had higher Charlson Comorbidity Index (p < 0.0001). There were no intergroup differences in tachycardia (22.5%[short-course] vs 23.3%[long-course]) or leukocytosis (67.1%[short-course] vs 64.4%[long-course]) at drain placement nor time to normalization for pulse, temperature or leukocytosis. There were no differences regarding Clostridium Difficile infection (5.0%[short-course] vs 1.6%[long-course]) or cholecystitis recurrence (8.8%[short-course] vs 10.9%[long-course]). No differences were observed regarding gallbladder-related unplanned readmissions (30-day:18.8%[short-course] vs 17.2%[long-course]; 90-day: 20.0%[short-course] vs 25.8%[long-course]). There were no 30- or 90-day mortality differences (overall mortality: 18.3%). CONCLUSION Post-cholecystostomy outcomes were comparable between short-course and long-course antibiotics, consistent with emerging literature supporting short-course antibiotics for intra-abdominal infection with source control.
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Abidi HH, Sawyer RG. More evidence for shortening antibiotic therapy in peritonitis: the DURAPOP trial. J Thorac Dis 2018; 10:S3160-S3161. [PMID: 30370104 DOI: 10.21037/jtd.2018.07.67] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Hira H Abidi
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, MI, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, MI, USA
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Abstract
PURPOSE OF REVIEW To summarize the recent evidence on the treatment of abdominal sepsis with a specific emphasis on the surgical treatment. RECENT FINDINGS A multitude of surgical approaches towards abdominal sepsis are practised. Recent evidence shows that immediate closure of the abdomen has a better outcome. A short course of antibiotics has a similar effect as a long course of antibiotics in patients with intra-abdominal infection without severe sepsis. SUMMARY Management of abdominal sepsis requires a multidisciplinary approach. Closing the abdomen permanently after source control and only reopening it in case of deterioration of the patient without other (percutaneous) options is the preferred strategy. There is no convincing evidence that damage control surgery is beneficial in patients with abdominal sepsis. If primary closure of the abdomen is impossible because of excessive visceral edema, delayed closure using negative pressure therapy with continuous mesh-mediated fascial traction shows the best results.
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37
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Shortened Courses of Antibiotics for Bacterial Infections: A Systematic Review of Randomized Controlled Trials. Pharmacotherapy 2018; 38:674-687. [DOI: 10.1002/phar.2118] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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38
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Abstract
BACKGROUND Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Early recognition and treatment are the cornerstones of management. METHODS Review of the English-language literature. RESULTS For both sepsis and septic shock "antimicrobials [should be] be initiated as soon as possible and within one hour" (Surviving Sepsis Campaign). The risk of progression from severe sepsis to septic shock increases 8% for each hour before antibiotics are started. Selection of antimicrobial agents is based on a combination of patient factors, predicted infecting organism(s), and local microbial resistance patterns. The initial drugs should have activity against typical gram-positive and gram-negative causative micro-organisms. Anaerobic coverage should be provided for intra-abdominal infections or others where anaerobes are significant pathogens. Empiric antifungal or antiviral therapy may be warranted. For patients with healthcare-associated infections, resistant micro-organisms will further complicate the choice of empiric antimicrobials. Recommendations are given for specific infections. CONCLUSION Early administration of broad-spectrum antimicrobial drugs is one of the most important, if not the most important, treatment for patients with sepsis or septic shock. Drugs should be initiated as soon as possible, and the choice of should take into account patient factors, common local pathogens, hospital antibiograms and resistance patterns, and the suspected source of infection. Antimicrobial agent therapy should be de-escalated as soon as possible.
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Affiliation(s)
- Sara A Buckman
- Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Isaiah R Turnbull
- Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - John E Mazuski
- Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
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39
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Nunez Lopez O, Cambiaso-Daniel J, Branski LK, Norbury WB, Herndon DN. Predicting and managing sepsis in burn patients: current perspectives. Ther Clin Risk Manag 2017; 13:1107-1117. [PMID: 28894374 PMCID: PMC5584891 DOI: 10.2147/tcrm.s119938] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Modern burn care has led to unprecedented survival rates in burn patients whose injuries were fatal a few decades ago. Along with improved survival, new challenges have emerged in the management of burn patients. Infections top the list of the most common complication after burns, and sepsis is the leading cause of death in both adult and pediatric burn patients. The diagnosis and management of sepsis in burns is complex as a tremendous hypermetabolic response secondary to burn injury can be superimposed on systemic infection, leading to organ dysfunction. The management of a septic burn patient represents a challenging scenario that is commonly encountered by providers caring for burn patients despite preventive efforts. Here, we discuss the current perspectives in the diagnosis and treatment of sepsis and septic shock in burn patients.
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Affiliation(s)
- Omar Nunez Lopez
- Department of Surgery, University of Texas Medical Branch.,Shriners Hospitals for Children, Galveston, TX, USA
| | - Janos Cambiaso-Daniel
- Department of Surgery, University of Texas Medical Branch.,Shriners Hospitals for Children, Galveston, TX, USA.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Ludwik K Branski
- Department of Surgery, University of Texas Medical Branch.,Shriners Hospitals for Children, Galveston, TX, USA
| | - William B Norbury
- Department of Surgery, University of Texas Medical Branch.,Shriners Hospitals for Children, Galveston, TX, USA
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch.,Shriners Hospitals for Children, Galveston, TX, USA.,Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, USA
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40
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Garnacho-Montero J, Arenzana-Seisdedos A, De Waele J, Kollef MH. To which extent can we decrease antibiotic duration in critically ill patients? Expert Rev Clin Pharmacol 2017; 10:1215-1223. [PMID: 28837364 DOI: 10.1080/17512433.2017.1369879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Inadequate empirical antibiotic therapy is associated with higher mortality in critically ill patients with severe infections. Nevertheless, prolonged duration of antibiotic treatment is also potentially harmful. Development of new infections with more resistant pathogens is one of the arguments against the administration of prolonged courses of antibiotics. Areas covered: We aim to describe the optimal duration of antimicrobial therapy in the most common infections affecting critically ill patients. A literature search was performed to identify all clinical trials, observational studies, meta-analysis, and reviews about this topic from PubMed. Expert commentary: Diverse observational studies have reported a poor outcome in critically ill patients without a documented infection who receive prolonged antibiotic therapy. We summarize the available information about the optimal duration of antimicrobial therapy in critically ill patients with severe infections including community-acquired pneumonia, intra-abdominal infections, bacteremia, meningitis and urinary-tract infections as well as the clinical consequences of short antimicrobial courses in certain severe infections. The utility of procalcitonin to reduce the duration of antibiotics is also discussed. Finally, we give clear recommendations about the length of treatment for the most common infections in critically ill patients.
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Affiliation(s)
- José Garnacho-Montero
- a Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen Macarena , Sevilla , Spain
| | - Angel Arenzana-Seisdedos
- a Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen Macarena , Sevilla , Spain
| | - Jan De Waele
- b Department of Critical Care Medicine , Ghent University Hospital , Ghent , Belgium
| | - Marin H Kollef
- c Pulmonary and Critical Care Division , Washington University School of Medicine , St. Louis MO , USA
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1883] [Impact Index Per Article: 269.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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42
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Soop M, Carlson GL. Recent developments in the surgical management of complex intra-abdominal infection. Br J Surg 2017; 104:e65-e74. [PMID: 28121035 DOI: 10.1002/bjs.10437] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Current guidance on the management of sepsis often applies to infection originating from abdominal or pelvic sources, which presents specific challenges and opportunities for efficient and rapid source control. Advances made in the past decade are presented in this article. METHODS A qualitative systematic review was undertaken by searching standard literature databases for English-language studies presenting original data on the clinical management of abdominal and pelvic complex infection in adults over the past 10 years. High-quality studies relevant to five topical themes that emerged during review were included. RESULTS Important developments and promising preliminary work are presented, relating to: imaging and other diagnostic modalities; antimicrobial therapy and the importance of antimicrobial stewardship; the particular challenges posed by fungal sepsis; novel techniques in percutaneous and endoscopic source control; and current issues relating to surgical source control and managing the abdominal wound. Logistical challenges relating to rapid access to cross-sectional imaging, interventional radiology and operating theatres need to be addressed so that international benchmarks can be met. CONCLUSION Important advances have been made in the diagnosis, non-operative and surgical control of abdominal or pelvic sources, which may improve outcomes in the future. Important areas for continued research include the diagnosis and therapy of fungal infection and the challenges of managing the open abdomen.
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Affiliation(s)
- M Soop
- Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - G L Carlson
- Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
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Katchanov J, Kreuels B, Maurer FP, Wöstmann K, Jochum J, König C, Seoudy K, Rohde H, Lohse AW, Wichmann D, Baehr M, Rothe C, Kluge S. Risk factors for excessively prolonged meropenem use in the intensive care setting: a case-contol study. BMC Infect Dis 2017; 17:131. [PMID: 28178922 PMCID: PMC5297215 DOI: 10.1186/s12879-017-2229-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/27/2017] [Indexed: 12/29/2022] Open
Abstract
Background Inappropriate use of broad-spectrum antimicrobials affects adversely both the individual patient and the general public. The aim of the study was to identify patients at risk for excessively prolonged carbapenem treatment in the ICU as a target for antimicrobial stewardship interventions. Methods Case–control study in a network of 11 ICUs of a university hospital. Patients with uninterrupted meropenem therapy (MT) > 4 weeks were compared to controls. Controls were defined as patients who stayed on the ICU > 4 weeks and received meropenem for ≤ 2 weeks. Associations between case–control status and potential risk factors were determined in a multivariate logistic regression model. Results Between 1st of January 2013 and 31st of December 2015, we identified 36 patients with uninterrupted MT > 4 weeks. Patients with prolonged MT were more likely to be surgical patients (72.2% of cases vs. 31.5% of controls; p ≤ 0.001) with peritonitis being the most common infection (n = 16, 44.4%). In the multivariate logistic regression model colonization with multidrug-resistant (MDR) Gram-negative bacteria (OR 7.52; 95% CI 1.88–30.14, p = 0.004) and the type of infection (peritonitis vs. pneumonia: OR 16.96, 95% CI 2.95–97.49) were associated with prolonged MT. Conclusion Surgical patients with peritonitis and patients with known colonization with MDR Gram-negative bacteria are at risk for excessively prolonged carbapenem therapy and represent an important target population for antimicrobial stewardship interventions.
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Affiliation(s)
- Juri Katchanov
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Benno Kreuels
- Division of Infectious Diseases and Tropical Medicine, First Medical Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Infectious Disease Epidemiology, Bernhard-Nocht-Institute for Tropical Medicine, Hamburg, Germany
| | - Florian P Maurer
- Department of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kai Wöstmann
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Jochum
- Division of Infectious Diseases and Tropical Medicine, First Medical Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kariem Seoudy
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Rohde
- Department of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- Division of Infectious Diseases and Tropical Medicine, First Medical Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominic Wichmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Michael Baehr
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Camilla Rothe
- Division of Infectious Diseases and Tropical Medicine, First Medical Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3674] [Impact Index Per Article: 524.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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45
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Rattan R, Allen CJ, Sawyer RG, Mazuski J, Duane TM, Askari R, Banton KL, Claridge JA, Coimbra R, Cuschieri J, Dellinger EP, Evans HL, Guidry CA, Miller PR, O'Neill PJ, Rotstein OD, West MA, Popovsky K, Namias N. Patients with Risk Factors for Complications Do Not Require Longer Antimicrobial Therapy for Complicated Intra-Abdominal Infection. Am Surg 2016. [DOI: 10.1177/000313481608200951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A prospective, multicenter, randomized controlled trial found that four days of antibiotics for source-controlled complicated intra-abdominal infection resulted in similar outcomes when compared with a longer duration. We hypothesized that patients with specific risk factors for complications also had similar outcomes. Short-course patients with obesity, diabetes, or Acute Physiology and Chronic Health Evaluation II ≥15 from the STOP-IT trial were compared with longer duration patients. Outcomes included incidence of and days to infectious complications, mortality, and length of stay. Obese and diabetic patients had similar incidences of and days to surgical site infection, recurrent intra-abdominal infection, extra-abdominal infection, and Clostridium difficile infection. Short- and long-course patients had similar incidences of complications among patients with Acute Physiology and Chronic Health Evaluation II ≥15. However, there were fewer days to the diagnosis of surgical site infection (9.5 ± 3.4 vs 21.6 ± 6.2, P = 0.010) and extra-abdominal infection (12.4 ± 6.9 vs 21.8 ± 6.1, P = 0.029) in the short-course group. Mortality and length of stay was similar for all groups. A short course of antibiotics in complicated intraabdominal infection with source control seems to have similar outcomes to a longer course in patients with diabetes, obesity, or increased severity of illness.
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Affiliation(s)
- Rishi Rattan
- University of Miami Miller School of Medicine, Miami, Florida
| | - Casey J. Allen
- University of Miami Miller School of Medicine, Miami, Florida
| | | | - John Mazuski
- Washington University School of Medicine, St. Louis, Missouri
| | | | - Reza Askari
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - Raul Coimbra
- University of California San Diego, San Diego, California
| | - Joseph Cuschieri
- University of Washington Harborview Medical Center, Seattle, Washington
| | | | - Heather L. Evans
- University of Washington Harborview Medical Center, Seattle, Washington
| | | | | | | | - Ori D. Rotstein
- University of Toronto St Michael's Hospital, Toronto, Ontario
| | - Michaela A. West
- University of California San Francisco, San Francisco, California
| | | | - Nicholas Namias
- University of Miami Miller School of Medicine, Miami, Florida
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