Appendectomy as a Risk Factor for Bacteremic Biliary Tract Infection Caused by Antibiotic-Resistant Pathogens

The distribution and antibiotic-resistant characteristics and risk factors of pathogens associated with clinical biliary tract infection in humans

Introduction

Biliary Infection in patients is a common and important phenomenon resulting in severe complications and high morbidity, while the distributions and drug resistance profiles of biliary bacteria and related risk factors are dynamic. This study explored the characteristics of and risk factors for biliary infection to promote the rational use of antibiotics in clinically.

Methods

Bacterial identification and drug susceptibility testing were completed using the Vitek 2 Compact analysis system. The distribution and antibiotic-resistant characteristics of 3,490 strains of biliary bacteria in patients at Nankai Hospital from 2019 to 2021 were analyzed using Whonet 5.6 and SPSS 26.0 software. We then retrospectively analyzed the clinical data and risk factors associated with 2,340 strains of Gram-negative bacilli, which were divided into multidrug-resistant bacteria (1,508 cases) and non-multidrug-resistant bacteria (832 cases) by a multivariate Cox regression model.

Results and discussion

A total of 3,490 pathogenic bacterial strains were isolated from bile samples, including 2,340 (67.05%) Gram-negative strains, 1,029 (29.48%) Gram-positive strains, and 109 (4.56%) fungal strains. The top five pathogenic bacteria were Escherichia coli, Klebsiella pneumoniae, Enterococcus faecium, Enterococcus faecalis, and Pseudomonas aeruginosa. The rate of Escherichia coli resistance to ciprofloxacin increased (p < 0.05), while the resistance to amikacin decreased (p < 0.05). The resistance of Klebsiella pneumoniae to cephalosporins, carbapenems, β-lactamase inhibitors, cephalases, aminoglycosides, and quinolones increased (p < 0.05), and the resistance of Pseudomonas aeruginosa to piperacillin, piperacillin/tazobactam, ticacillin/clavulanic acid, and amicacin declined significantly (p < 0.05). The resistance of Enterococcus faecium to tetracycline increased by year (p < 0.05), and the resistance of Enterococcus faecalis to erythromycin and high-concentration gentamicin declined (p < 0.05). Multivariate logistic regression analysis suggested that the administration of third- or fourth-generation cephalosporins was an independent risk factor for biliary infection. In summary, Gram-negative bacilli were the most common pathogenic bacteria isolated from biliary infection patients, especially Escherichia coli, and the rates and patterns of drug resistance were high and in constant flux; therefore, rational antimicrobial drug use should be carried out considering risk factors.

Colonoscopy in the diagnosis and management of appendiceal disease

In this editorial, we comment on the article published in the recent issue of the World Journal of Gastrointestinal Endoscopy. We focused on the understanding of appendiceal disease, and the various options for diagnosis and treatment via endoscopy. Some factors affecting the diagnosis and management of appendiceal diseases are also discussed. The existence of any organ has its natural rationality, and the appendix is such a magical organ. A growing number of experts and scholars have gradually come to a consensus that the appendix is not a useless evolutionary relic. There are many lymphocytes and lymph nodes in the appendix wall, which has a strong immune function, and this function is particularly important for children and adolescents. Many intestinal probiotics in the appendix are very helpful for maintaining the balance of the intestinal flora. With the continuous progress of endoscopic technology, endoscopic treatment involving preservation of the appendix has shown great advantages over surgery. In the diagnosis of appendiceal inflammation and neoplasms, colonoscopy, endoscopic retrograde appendicography and choledochoscopy help assess conditions of the appendix. Endoscopic retrograde appendicitis therapy, abscess drainage under colonoscopy, fenestration of abscess under colonoscopy, and endoscopic or natural orifice transluminal endoscopic surgery resection of appendiceal neoplasms are safe and effective endoscopic treatments for appendiceal disease. New breakthroughs in the application of endoscopy in the appendix are expected to occur in the near future.

Korean Guidelines for Use of Antibiotics for Intra-abdominal Infections in Adults

The guidelines are intended to provide practical information for the correct use of antibiotics for intra-abdominal infections in Korea. With the aim of realizing evidence-based treatment, these guidelines for the use of antibiotics were written to help clinicians find answers to key clinical questions that arise in the course of patient care, using the latest research results based on systematic literature review. The guidelines were prepared in consideration of the data on the causative pathogens of intra-abdominal infections in Korea, the antibiotic susceptibility of the causative pathogens, and the antibiotics available in Korea.

Children with appendectomy have increased risk of future sepsis: Real-world data in Taiwan

BACKGROUND

Appendectomy is one of the most commonly performed surgeries worldwide. Sepsis is a major aetiology of morbidity and mortality in children. Our preliminary research revealed a positive correlation amongst appendectomy and future risk of sepsis in adults. However, to date, the relationship between appendectomy and future risk of sepsis in children remains unknown. The aim of this research was to investigate the relationship between appendectomy and the hazard of future sepsis in children.

METHODS

We applied a nationwide population-based cohort to assess whether children who received appendectomy were at increased risk of subsequent sepsis. Overall, 57 261 subjects aged below 18 undergoing appendectomy as appendectomy group and 57 261 matched controls were identified as a non-appendectomy group from the National Health Insurance Research Database in Taiwan. We use propensity score analysis to match the age, sex, urbanisation level and parental occupation at the ratio to 1:1. Multiple Cox regression and stratified analyses were used to appraise the adjusted hazard ratio (aHR) for developing sepsis in children.

RESULTS

Children who received appendectomy had a 2.38 times higher risk (aHR: 2.38; 95% confidence interval [CI] = 1.98, 2.87) of developing sepsis than those who did not, and the risk was higher in all age groups (aHR: 2.98, 95% CI = 1.84, 4.83; aHR: 2.45, 95% CI = 1.08, 2.05; aHR: 2.18, 95% CI = 1.70, 2.80 in children aged <6, 7-12 and 13-18 years, respectively). Patients with <1-year follow-up showed a 4.53-fold risk of sepsis in the appendectomy cohort (aHR: 4.53, 95% CI = 2.80, 7.35). Patients with 1-4 and ≥5 years' follow-up showed a 2.19- and 1.94-times risk of sepsis (aHR: 2.19, 95% CI = 1.61, 2.97; aHR: 1.94, 95% CI = 1.48, 2.56 in 1-4 and >5 years, respectively).

CONCLUSION

Appendectomy was correlative to a 2.38-fold increased future sepsis risk in children, and the risk in all age groups was higher. More studies to interpret the possible biological mechanisms of the associations amongst sepsis and appendectomy are warranted.

Appendectomy Is Associated With Alteration of Human Gut Bacterial and Fungal Communities

Recent research has revealed the importance of the appendix in regulating the intestinal microbiota and mucosal immunity. However, the changes that occur in human gut microbial communities after appendectomy have never been analyzed. We assessed the alterations in gut bacterial and fungal populations associated with a history of appendectomy. In this cross-sectional study, we investigated the association between appendectomy and the gut microbiome using 16S and ITS2 sequencing on fecal samples from 30 healthy individuals with prior appendectomy (HwA) and 30 healthy individuals without appendectomy (HwoA). Analysis showed that the gut bacterial composition of samples from HwA was less diverse than that of samples from HwoA and had a lower abundance of Roseburia, Barnesiella, Butyricicoccus, Odoribacter, and Butyricimonas species, most of which were short-chain fatty acids-producing microbes. The HwA subgroup analysis indicated a trend toward restoration of the HwoA bacterial microbiome over time after appendectomy. HwA had higher gut fungi composition and diversity than HwoA, even 5 years after appendectomy. Compared with those in samples from HwoA, the abundance correlation networks in samples from HwA displayed more complex fungal–fungal and fungal–bacterial community interactions. This study revealed a marked impact of appendectomy on gut bacteria and fungi, which was particularly durable for fungi.

Long-term effects of appendectomy in humans: is it the optimal management of appendicitis?

INTRODUCTION

Appendectomy remains the gold standard for treating uncomplicated and complicated appendicitis. However, the vermiform appendix may play a significant role in the immune system (secondary immune function) and maintain a reservoir of the normal microbiome for the human body. The aim of this study was to summarize the long-term effects after appendectomy and discuss whether appendectomy is suitable for all appendicitis patients.

AREAS COVERED

A comprehensive and unbiased literature search was performed in PubMed. The terms 'appendix,' 'appendicitis,' 'appendectomy,' and 'endoscopic retrograde appendicitis therapy' were searched in the title and/or abstract. This review summarizes the long-term effects of appendectomy on some diseases in humans and describes three methods including appendectomy, medical treatment, and an 'organ-sparing' technique, named endoscopic retrograde appendicitis therapy (ERAT) to treat appendicitis.

EXPERT OPINION

Appendectomy remains the first-line therapy for appendicitis. The patient's problem is appendix, not appendicitis. If we treat appendicitis, the problem should be resolved. During COVID-19, an initial antibiotic treatment of mild appendicitis represents a promising strategy. For patients who are worried about the long-term adverse effect after appendectomy and have a strong desire to preserve the appendix and are aware of the risk of appendicitis recurrence, medical treatment, or ERAT could be proposed.

Developing a risk prediction model for multidrug-resistant bacterial infection in patients with biliary tract infection

BACKGROUND/AIMS

The aim of this study was to develop a tool to predict multidrug-resistant bacteria infections among patients with biliary tract infection for targeted therapy.

PATIENTS AND METHODS

We conducted a single-center retrospective descriptive study from January 2016 to December 2018. Univariate and multivariable logistic regression analysis were used to identify independent risk factors of multidrug-resistant bacterial infections. A nomogram was constructed according to multivariable regression model. Moreover, the clinical usefulness of the nomogram was estimated by decision curve analysis.

RESULTS

121 inpatients were randomly divided into a training cohort (n = 79) and validation cohort (n = 42). In multivariate analysis, 5 factors were associated with biliary tract infections caused by multidrug-resistant bacterial infections: aspartate aminotransferase (Odds ratio (OR), 13.771; 95% confidence interval (CI), 3.747-64.958; P < 0.001), previous antibiotic use within 90 days (OR, 4.130; 95% CI, 1.192-16.471; P = 0.032), absolute neutrophil count (OR, 3.491; 95% CI, 1.066-12.851; P = 0.046), previous biliary surgery (OR, 3.303; 95% CI, 0.910-13.614; P = 0.079), and hemoglobin (OR, 0.146; 95% CI, 0.030-0.576; P = 0.009). The nomogram model was constructed based on these variables, and showed good calibration and discrimination in the training set [area under the curve (AUC), 0.86] and in the validation set (AUC, 0.799). The decision curve analysis demonstrated the clinical usefulness of our nomogram. Using the nomogram score, high risk and low risk patients with multidrug-resistant bacterial infection could be differentiated.

CONCLUSIONS

This simple bedside prediction tool to predict multidrug-resistant bacterial infection can help clinicians identify low versus high risk patients as well as choose appropriate, timely initial empirical antibiotics therapy. This model should be validated before it is widely applied in clinical settings.

Increased risk of gallstones after appendectomy: A longitudinal follow-up study using a national sample cohort

To evaluate the association between appendectomy and the occurrence of gallstones using a national sample cohort from Korea.The Korean National Health Insurance Service-National Sample Cohort was collected from 2002 to 2013. We extracted data for patients who had undergone appendectomy (n = 14,955) and a 1:4 matched control group (n = 59,820) and then analyzed the occurrence of gallstones. The patients were matched according to age, sex, income, region of residence, hypertension, diabetes mellitus, and history of dyslipidemia. Appendectomies were identified using operation codes (Q2860-Q2863) for appendicitis alone (International Classification of Disease-10: K35). Gallstones were diagnosed if the corresponding International Classification of Disease-10 code (K80) was reported ≥2 times. Crude (simple) and adjusted hazard ratios (HRs) were analyzed using stratified Cox proportional hazard models, and 95% confidence intervals were calculated. Subgroup analyses were performed based on age, sex, and time period after appendectomy.The adjusted HR for gallstones was 1.78 (95% confidence interval = 1.51-2.09, P < .001) in the appendectomy group. Consistent HRs were found in the analyses of all the subgroups determined using age and sex, with the exception of men ≥60 years of age. The risk of gallstones was increased during the first year after appendectomy.The occurrence of gallstones was increased in the patients who had undergone appendectomy.