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Tian BWCA, Agnoletti V, Ansaloni L, Coccolini F, Bravi F, Sartelli M, Vallicelli C, Catena F. Management of Intra-Abdominal Infections: The Role of Procalcitonin. Antibiotics (Basel) 2023; 12:1406. [PMID: 37760703 PMCID: PMC10525176 DOI: 10.3390/antibiotics12091406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with intra-abdominal sepsis suffer from significant mortality and morbidity. The main pillars of treatment for intra-abdominal infections are (1) source control and (2) early delivery of antibiotics. Antibiotic therapy should be started as soon as possible. However, the duration of antibiotics remains a matter of debate. Prolonged antibiotic delivery can lead to increased microbial resistance and the development of nosocomial infections. There has been much research on biomarkers and their ability to aid the decision on when to stop antibiotics. Some of these biomarkers include interleukins, C-reactive protein (CRP) and procalcitonin (PCT). PCT's value as a biomarker has been a focus area of research in recent years. Most studies use either a cut-off value of 0.50 ng/mL or an >80% reduction in PCT levels to determine when to stop antibiotics. This paper performs a literature review and provides a synthesized up-to-date global overview on the value of PCT in managing intra-abdominal infections.
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Affiliation(s)
- Brian W. C. A. Tian
- Department of General Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore;
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, M. Bufalini Hospital, 47521 Cesena, Italy
| | - Luca Ansaloni
- Department of Surgery, Pavia University Hospital, 27100 Pavia, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, 56126 Pisa, Italy
| | | | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Carlo Vallicelli
- Department of Emergency and Trauma Surgery, M. Bufalini Hospital, 47521 Cesena, Italy
| | - Fausto Catena
- Department of Surgery, “Maurizio Bufalini” Hospital, 47521 Cesena, Italy
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Fuhrer AE, Sukhotnik I, Ben-Shahar Y, Weinberg M, Koppelmann T. Predictive Value of Alvarado Score and Pediatric Appendicitis Score in the Success of Nonoperative Management for Simple Acute Appendicitis in Children. Eur J Pediatr Surg 2021; 31:95-101. [PMID: 33080628 DOI: 10.1055/s-0040-1718406] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION During the past decade, nonoperative management (NOM) for simple acute appendicitis (SAA) in children has been proven safe with noninferior complications rate. The aim of this study was to examine Alvarado score and pediatric appendicitis score (PAS) together with other factors in predicting failure of NOM in children presenting with SAA. MATERIALS AND METHODS Patients aged 5 to 18 years admitted to our department between 2017 and 2019 diagnosed with SAA were given a choice between surgical management and NOM. We divided the NOM patients into two groups: successful treatment and failed NOM, comparing their files for Alvarado score and PAS and other clinical and demographic factors, with a mean follow-up of 7 months. Failure was determined as need for appendectomy following conservative treatment due to any reason. RESULTS A total of 85 patients answered criteria and chose NOM. Overall failure rate was 32.9%. We found no difference in the mean Alvarado score and PAS as well as in each component of both scores between success and failed NOM groups. However, when using the risk classification of the scores, we found a significant correlation between high-risk Alvarado score and failed NOM. After adjusting for age, gender, duration of symptoms, diagnosis of tip appendicitis, and presence of appendicolith, the odds of failure were four times higher among high-risk Alvarado group. CONCLUSION Alvarado score of 7 or higher, older age, and diagnosis of an appendicolith on imaging are possible predictors for failure of NOM for SAA in children.
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Affiliation(s)
- Audelia Eshel Fuhrer
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Igor Sukhotnik
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Ben-Shahar
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark Weinberg
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Koppelmann
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Comparison of Clinical Outcomes Between Laparoscopic and Open Extensive Resection for Complicated Appendicitis: Retrospective Observational Study. Surg Laparosc Endosc Percutan Tech 2021; 31:448-452. [PMID: 34398129 DOI: 10.1097/sle.0000000000000903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 11/02/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The feasibility and safety of laparoscopic extensive resection (ER) for complicated appendicitis (CA) has not been clarified. We assessed the feasibility of laparoscopic ER versus open ER for CA. METHODS We retrospectively enrolled consecutive 983 patients who underwent emergency surgery for appendicitis, including 91 patients who underwent ER for CA, between April 2007 and October 2019. RESULTS Thirty-three patients underwent laparoscopic ER, and 58 patients underwent open ER. There were no significant differences in the reasons for performing ER between laparoscopic ER and open ER. The rates of suspicious for malignant tumor did not differ between laparoscopic and open ER [15.2% (5/33) vs. 17.2% (10/58)]. Blood loss was less in laparoscopic ER than in open ER (P=0.028). Superficial surgical site infection was less frequent in laparoscopic ER than in open ER (P=0.047). In addition, laparoscopic ER tended to be associated with a shorter hospital stay, lower rate of postoperative ileus, and higher rate of intra-abdominal abscess. CONCLUSION Laparoscopic ER is feasible, and it is associated with less intraoperative blood loss and a lower frequency of postoperative superficial surgical site infection than open ER.
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Gao Z, Li M, Zhou H, Liang Y, Zheng C, Li S, Zhang T, Deng W. Complicated appendicitis are common during the epidemic period of 2019 novel coronavirus (2019-nCoV). Asian J Surg 2020; 43:1002-1005. [PMID: 32863144 PMCID: PMC7444978 DOI: 10.1016/j.asjsur.2020.07.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/20/2020] [Accepted: 07/29/2020] [Indexed: 01/08/2023] Open
Abstract
Objectives To assess the prevalence of complicated appendicitis (including gangrene, abscess and perforation) after the outbreak of the 2019-nCoV epidemic and to identify the risk factors associated with complicated appendicitis. Methods Two groups were established in the study consisting of: one group for cases of acute appendicitis before the 2019-nCoV epidemic (before January 1, 2020; pre-epidemic group) and another group for those after the epidemic outbreak (after January 1, 2020; epidemic group). These two groups were compared in terms of demographic and clinical characteristics, prevalence of complicated appendicitis, and treatment intention. A multivariate analysis model using binary logistic regression was constructed. Results A total of 163 patients were included in this study, with 105 in the pre-epidemic group and 58 in the epidemic group. In the epidemic group, the interval from the onset of symptoms to admission was 65.0 h, which is significantly longer than the 17.3 h interval noted in the pre-epidemic group (P < 0.001). The prevalence of complicated appendicitis after the epidemic outbreak was significantly higher than before the outbreak (51.7% vs. 12.4%, P < 0.001). In addition, the epidemic group had a lower score of patient’s intention to seek treatment than the pre-epidemic group (9.5 ± 2.7 vs. 3.4 ± 2.6, P < 0.001). Based on the multivariate analysis, the risk factors for complicated appendicitis included the time from symptoms onset to admission (OR = 1.075) and the patients’ intention to receive treatment (OR = 0.541). Conclusion Complicated appendicitis was more common in patients with acute appendicitis after the outbreak of the 2019-nCoV epidemic.
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Affiliation(s)
- Zhiguang Gao
- Department of General Surgery, the Affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan 523320, China.
| | - Min Li
- Department of General Surgery, the Affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan 523320, China.
| | - Huabin Zhou
- Department of General Surgery, the Affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan 523320, China.
| | - Yuzhi Liang
- Department of Medical Imaging, the Affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan 523320, China.
| | - Chao Zheng
- Department of General Surgery, the Affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan 523320, China.
| | - Suming Li
- Department of General Surgery, the Affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan 523320, China.
| | | | - Weijun Deng
- Department of General Surgery, the Affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan 523320, China.
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Augustin G, di Saverio S. MRI is Mandatory for the Assignment into Antibiotic Treatment or Appendectomy Group of Patients During Pregnancy. Am J Med 2020; 133:e208. [PMID: 32450952 DOI: 10.1016/j.amjmed.2019.06.043] [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] [Received: 06/28/2019] [Accepted: 06/28/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Salomone di Saverio
- Cambridge Colorectal Unit, Addenbrooke's University Hospital NHS Foundation Trust, Cambridge, UK
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Dhillon NK, Barmparas G, Lin TL, Alban RF, Melo N, Yang AR, Margulies DR, Ley EJ. Unexpected complicated appendicitis in the elderly diagnosed with acute appendicitis. Am J Surg 2019; 218:1219-1222. [PMID: 31481154 DOI: 10.1016/j.amjsurg.2019.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/10/2019] [Accepted: 08/16/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND This study determined the prevalence of complicated appendicitis in elderly patients diagnosed preoperatively with uncomplicated appendicitis. METHODS Patients with a preoperative diagnosis of uncomplicated appendicitis at an academic hospital from 11/2013 to 05/2017 were reviewed. Patients ≥65 years were compared to those younger. Pathology reports were categorized as either uncomplicated or complicated (COMP). The primary outcome was the prevalence of COMP appendicitis. RESULTS The prevalence of COMP appendicitis increased with age after 20 years with an abrupt increase after 65 years. Patients ≥65 years were more likely to have COMP appendicitis (48.1% vs. 15.5%; OR: 5.1; p < 0.01) and prolonged stays (3.8 vs. 2.3 days; p < 0.01). CONCLUSION Nearly half of elderly patients had pathologic confirmation of complicated appendicitis despite no preoperative clinical or radiographic suspicion for complicated appendicitis. Nonoperative management of acute appendicitis in the elderly may not be appropriate due to the high rate of unexpected complicated appendicitis.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ting-Lung Lin
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Rodrigo F Alban
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Nicolas Melo
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Audrey R Yang
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Li Y, Zhang Z, Cheang I, Li X. Procalcitonin as an excellent differential marker between uncomplicated and complicated acute appendicitis in adult patients. Eur J Trauma Emerg Surg 2019; 46:853-858. [PMID: 31087109 DOI: 10.1007/s00068-019-01116-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/26/2019] [Indexed: 12/11/2022]
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Talan DA, Saltzman DJ, DeUgarte DA, Moran GJ. Methods of conservative antibiotic treatment of acute uncomplicated appendicitis: A systematic review. J Trauma Acute Care Surg 2019; 86:722-736. [PMID: 30516592 PMCID: PMC6437084 DOI: 10.1097/ta.0000000000002137] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/09/2018] [Accepted: 10/29/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Meta-analyses and a recent guideline acknowledge that conservative management of uncomplicated appendicitis with antibiotics can be successful for patients who wish to avoid surgery. However, guidance as to specific management does not exist. METHODS PUBMED and EMBASE search of trials describing methods of conservative treatment was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS Thirty-four studies involving 2,944 antibiotic-treated participants were identified. The greatest experience with conservative treatment is in persons 5 to 50 years of age. In most trials, imaging was used to confirm localized appendicitis without evidence of abscess, phlegmon, or tumor. Antibiotics regimens were generally consistent with intra-abdominal infection treatment guidelines and used for a total of 7 to 10 days. Approaches ranged from 3-day hospitalization on parenteral agents to same-day hospital or ED discharge of stable patients with outpatient oral antibiotics. Minimum time allowed before response was evaluated varied from 8 to 72 hours. Although pain was a common criterion for nonresponse and appendectomy, analgesic regimens were poorly described. Trials differed in use of other response indicators, that is, white blood cell count, C-reactive protein, and reimaging. Diet ranged from restriction for 48 hours to as tolerated. Initial response rates were generally greater than 90% and most participants improved by 24 to 48 hours, with no related severe sepsis or deaths. In most studies, appendectomy was recommended for recurrence; however, in several, patients had antibiotic retreatment with success. CONCLUSION While further investigation of conservative treatment is ongoing, patients considering this approach should be advised and managed according to study methods and related guidelines to promote informed shared decision-making and optimize their chance of similar outcomes as described in published trials. Future studies that address biases associated with enrollment and response evaluation, employ best-practice pain control and antibiotic selection, better define cancer risk, and explore longer time thresholds for response, minimized diet restriction and hospital stays, and antibiotic re-treatment will further our understanding of the potential effectiveness of conservative management. LEVEL OF EVIDENCE Systematic review, level II.
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Affiliation(s)
- David A Talan
- From the Department of Emergency Medicine (D.A.T., G.J.M.); Division of Infectious Diseases (D.A.T., G.J.M.), Department of Medicine; Department of Surgery (D.J.S.), Olive View-UCLA Medical Center, Sylmar; and Department of Surgery (D.A.D.), Division of Pediatric Surgery, Harbor-UCLA Medical Center, Torrance, California
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