Complicated intra-abdominal infections in Europe: a comprehensive review of the CIAO study

Epidemiological analysis of intra-abdominal infections in Italy from the Italian register of complicated intra-abdominal infections-the IRIS study: a prospective observational nationwide study

BACKGROUND

Intra-abdominal infections (IAIs) are common and severe surgical emergencies associated with high morbidity and mortality. In recent years, there has been a worldwide increase in antimicrobial resistance associated with intra-abdominal infections, responsible for a significant increase in mortality rates. To improve the quality of treatment, it is crucial to understand the underlying local epidemiology, clinical implications, and proper management of antimicrobial resistance, for both community- and hospital-acquired infections. The IRIS study (Italian Register of Complicated Intra-abdominal InfectionS) aims to investigate the epidemiology and initial management of complicated IAIs (cIAIs) in Italy.

MATERIAL AND METHOD

This is a prospective, observational, nationwide (Italy), multicentre study. approved by the coordinating centre ethic committee (Local Research Ethics Committee of Pisa (Prot n 56478//2019). All consecutively hospitalized patients (older than 16 years of age) with diagnosis of cIAIs undergoing surgery, interventional drainage or conservative treatment have been included.

RESULTS

4530 patients included from 23 different Italian hospitals. Community Acquired infection represented the 70.9% of all the cases. Among appendicitis, we found that 98.2% of the cases were community acquired (CA) and 1.8% Healthcare-associated (HA) infections. We observed that CA represented the 94.2% and HA 5.8% of Gastro Duodenal perforation cases. The majority of HA infections were represented by colonic perforation and diverticulitis (28.3%) followed by small bowel occlusion (19%) and intestinal ischemia (18%). 27.8% of patients presented in septic shock. Microbiological Samples were collected from 3208 (70.8%) patients. Among 3041 intrabdominal sample 48.8% resulted positive. The major pathogens involved in intra-abdominal infections were found to be E.coli (45.6%). During hospital stay, empiric antimicrobial therapy was administered in 78.4% of patients. Amoxicillin/clavulanate was the most common antibiotic used (in 30.1% appendicitis, 30% bowel occlusion, 30.5% of cholecystitis, 51% complicated abdominal wall hernia, 55% small bowel perforation) followed by piperacillin/tazobactam (13.3% colonic perforation and diverticulitis, 22.6% cholecystitis, 24.2% intestinal ischemia, 28.6% pancreatitis). Empiric antifungal therapy was administered in 2.6% of patients with no sign of sepsis, 3.1% of patients with clinical sign of sepsis and 4.1% of patients with septic shock. Azoles was administered in 49.2% of patients that received empiric antifungal therapy. The overall mortality rate was 5.13% (235/4350). 16.5% of patients required ICU (748/4350). In accordance with mortality, it is important to highlight that 35.7% of small bowel perforation, 27.6% of colonic perforation and diverticulitis, 25.6% of intestinal ischemia and 24.6% of gastroduodenal complications required ICU.

CONCLUSION

Antibiotic stewardship programs and correct antimicrobial and antimycotic prescription campaigns are necessary to ulteriorly improve the adequacy of drug usage and reduce the resistances burden. This will help in improving the care and the cure of the next generations.

Gut microbes of the cecum versus the colon drive more severe lethality and multi-organ damage

Intestinal perforations lead to a high risk of sepsis-associated morbidity and multi-organ dysfunctions. A perforation allows intestinal contents (IC) to enter the peritoneal cavity, causing abdominal infections. Right- and left-sided perforations have different prognoses in humans, but the mechanisms associated with different cecum and colon perforations remain unclear. This study investigates how gut flora influences outcomes from perforations at different sites in mice. Using fecal-induced peritonitis mouse model, isolated IC from the cecum or colon was injected peritoneally at 2 mg/kg. Bacterial burden was quantified with quantitative PCR, and microbial communities were analyzed using 16S rRNA gene sequencing. Survival rates were monitored, and blood biochemical indices, histological changes, cytokines expression, immunological signaling and multiple-organ damage were assessed at 16 h post-injections. The results showed cecum IC developed more severe sepsis than colon IC, with shorter median survival time and greater multi-organ damage. Mice treated with cecum IC displayed elevated tissue damage markers in the liver, heart, and kidneys, contributing to worsened pathology. This was likely driven by systematic inflammatory cytokines production and lung inflammation. Mechanistically, cecum IC triggered stronger cGAS-STING and TBK1-NF-κB signaling, promoting systemic inflammation compared to the colon IC. Moreover, bacterial analysis demonstrated that cecum IC carry a higher bacterial burden than colon IC and exhibit a different microbial community. A detailed microbiome comparison revealed an increased abundance of potentially pathogenic bacteria in the cecum IC. These findings suggest that the site of intestinal perforation influences sepsis severity, with the cecum being associated with a higher bacterial burden and a relatively increased abundance of potentially pathogenic bacteria compared to the colon. Our findings first compared the lethality associated with the microbial composition of the cecum and colon, indicating the perforation site could help providers predict the severity of sepsis, thereby introducing a novel perspective to microbiology and sepsis research.

Surgical management of complicated diverticulitis: systematic review and individual patient data network meta-analysis : An EAES/ESCP collaborative project

BACKGROUND

We performed a systematic review and network meta-analysis (NMA) of individualized patient data (IPD) to inform the development of evidence-informed clinical practice recommendations.

METHODS

We searched MEDLINE, Embase, and Cochrane Central in October 2023 to identify RCTs comparing Hartmann's resection (HR), primary resection and anastomosis (PRA), or laparoscopic peritoneal lavage (LPL) among patients with class Ib-IV Hinchey diverticulitis. Outcomes of interest were prioritized by an international, multidisciplinary panel including two patient partners. Article screening, data extraction for IPD, and risk of bias appraisal were performed by two reviewers. We used a random-effects NMA to synthesize direct and indirect evidence. Heterogeneity was evaluated using the I2 statistic. The panel appraised the certainty of the evidence using GRADE and CINeMA.

RESULTS

Fourteen reports of seven RCTs were derived from 4,659 articles. IPD data were available for 595/678 patients (88.8%) across trials. Patients had a mean age ± SD of 64.61 ± 13.64 years and a mean BMI ± SD of 26.12 ± 5.20 kg/m2, representing Hinchey classes I (1.2%), II (1.0%) III (76.3%), and IV (12.1%), respectively. Using minimal important difference thresholds, in-hospital/30-day mortality was higher among patients receiving LPL versus HR [42 more per 1000, 95% CI (41 fewer to 331 more), moderate effect; low certainty] as well as PRA [45 more per 1000 patients, 95% CI (33 fewer to 340 more) moderate effect; low certainty] without heterogeneity (I2 = 0%). Among 417 patients from four trials, there was a lower stoma rate among patients receiving PRA versus LPL [539 fewer per 1000, 95% CI (647 fewer to 306 fewer), large effect; low certainty].

CONCLUSION

PRA likely confers a lower stoma rate at 1 year compared to HR, while there may be no difference in 30-day/in-hospital mortality. LPL likely confers a higher in-hospital/30-day mortality rate compared to HR and PRA.

The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update

Background: The Surgical Infection Society (SIS) published evidence-based guidelines for the management of intra-abdominal infection (IAI) in 1992, 2002, 2010, and 2017. Here, we present the most recent guideline update based on a systematic review of current literature. Methods: The writing group, including current and former members of the SIS Therapeutics and Guidelines Committee and other individuals with content or guideline expertise within the SIS, working with a professional librarian, performed a systematic review using PubMed/Medline, the Cochrane Library, Embase, and Web of Science from 2016 until February 2024. Keyword descriptors combined "surgical site infections" or "intra-abdominal infections" in adults limited to randomized controlled trials, systematic reviews, and meta-analyses. Additional relevant publications not in the initial search but identified during literature review were included. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was utilized to evaluate the evidence. The strength of each recommendation was rated strong (1) or weak (2). The quality of the evidence was rated high (A), moderate (B), or weak (C). The guideline contains new recommendations and updates to recommendations from previous IAI guideline versions. Final recommendations were developed by an iterative process. All writing group members voted to accept or reject each recommendation. Results: This updated evidence-based guideline contains recommendations from the SIS for the treatment of adult patients with IAI. Evidence-based recommendations were developed for antimicrobial agent selection, timing, route of administration, duration, and de-escalation; timing of source control; treatment of specific pathogens; treatment of specific intra-abdominal disease processes; and implementation of hospital-based antimicrobial agent stewardship programs. Summary: This document contains the most up-to-date recommendations from the SIS on the prevention and management of IAI in adult patients.

Management of intra-abdominal infections: recommendations by the Italian council for the optimization of antimicrobial use

Intra-abdominal infections (IAIs) are common surgical emergencies and are an important cause of morbidity and mortality in hospital settings, particularly if poorly managed. The cornerstones of effective IAIs management include early diagnosis, adequate source control, appropriate antimicrobial therapy, and early physiologic stabilization using intravenous fluids and vasopressor agents in critically ill patients. Adequate empiric antimicrobial therapy in patients with IAIs is of paramount importance because inappropriate antimicrobial therapy is associated with poor outcomes. Optimizing antimicrobial prescriptions improves treatment effectiveness, increases patients' safety, and minimizes the risk of opportunistic infections (such as Clostridioides difficile) and antimicrobial resistance selection. The growing emergence of multi-drug resistant organisms has caused an impending crisis with alarming implications, especially regarding Gram-negative bacteria. The Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use promoted a consensus conference on the antimicrobial management of IAIs, including emergency medicine specialists, radiologists, surgeons, intensivists, infectious disease specialists, clinical pharmacologists, hospital pharmacists, microbiologists and public health specialists. Relevant clinical questions were constructed by the Organizational Committee in order to investigate the topic. The expert panel produced recommendation statements based on the best scientific evidence from PubMed and EMBASE Library and experts' opinions. The statements were planned and graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence. On November 10, 2023, the experts met in Mestre (Italy) to debate the statements. After the approval of the statements, the expert panel met via email and virtual meetings to prepare and revise the definitive document. This document represents the executive summary of the consensus conference and comprises three sections. The first section focuses on the general principles of diagnosis and treatment of IAIs. The second section provides twenty-three evidence-based recommendations for the antimicrobial therapy of IAIs. The third section presents eight clinical diagnostic-therapeutic pathways for the most common IAIs. The document has been endorsed by the Italian Society of Surgery.

Timing of surgical operation for patients with intra-abdominal infection: A systematic review and meta-analysis

BACKGROUND

Intra-abdominal infections (IAIs) is the most common type of surgical infection, with high associated morbidity and mortality rates. In recent years, due to the use of antibiotics, various drug-resistant bacteria have emerged, making the treatment of abdominal infections more challenging. Early surgical exploration can reduce the mortality of patients with abdominal infection and the occurrence of complications. However, available evidence regarding the optimal timing of IAI surgery is still weak. In study, we compared the effects of operation time on patients with abdominal cavity infection and tried to confirm the best timing of surgery.

AIM

To assess the efficacy of early vs delayed surgical exploration in the treatment of IAI, in terms of overall mortality.

METHODS

A systematic literature search was performed using PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Ovid, and ScienceDirect. The systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses method. Based on the timing of the surgical operation, we divided the literature into two groups: Early surgery and delayed surgery. For the early and delayed surgery groups, the intervention was performed with and after 12 h of the initial surgical intervention, respectively. The main outcome measure was the mortality rate. The literature search was performed from May 5 to 20, 2021. We also searched the World Health Organization International Clinical Trials Registry Platform search portal and ClinicalTrials.gov on May 20, 2021, for ongoing trials. This study was registered with the International Prospective Register of Systematic Reviews.

RESULTS

We identified nine eligible trial comparisons. Early surgical exploration of patients with IAIs (performed within 12 h) has significantly reduced the mortality and complications of patients, improved the survival rate, and shortened the hospital stay.

CONCLUSION

Early surgical exploration within 12 h may be more effective for the treatment of IAIs relative to a delayed operation.

Association between Intraoperative Early Warning Score and Mortality and In-Hospital Stay in Lower Gastrointestinal Spontaneous Perforation

Background

Early warning scores (EWSs) can be easily calculated from physiological indices; however, the extent to which intraoperative EWSs and the corresponding changes are associated with patient prognosis is unknown. In this study, we investigated whether EWS and the corresponding time-related changes are associated with patient outcomes during the anesthetic management of lower gastrointestinal perforation.

Methods

This was a single-center, retrospective cohort study conducted at a tertiary emergency care center. Adult patients who underwent surgery for spontaneous lower gastrointestinal perforations between September 1, 2012, and December 31, 2019, were included. The National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) were calculated based on the intraoperative physiological indices, and the associations with in-hospital death and length of hospital stay were investigated.

Results

A total of 101 patients were analyzed. The median age was 70 years, and there were 11 cases of in-hospital death (mortality rate: 10.9%). There was a significant association between the intraoperative maximum NEWS and in-hospital death (odds ratio (OR): 1.60, 95% confidence interval (CI): 1.10-2.32, p=0.013) and change from initial to maximum NEWS (OR: 1.60, 95% CI: 1.07-2.40, p=0.023) in the crude analysis. However, when adjustments were made for confounding factors, no statistically significant associations were found. Other intraoperative EWS values and changes were not significantly associated with the investigated outcomes. The preoperative sepsis-related organ failure assessment score and the intraoperative base excess value were significantly associated with in-hospital death.

Conclusions

No clear association was observed between EWSs and corresponding changes and in-hospital death in cases of lower gastrointestinal perforation. The preoperative sepsis-related organ failure assessment score and intraoperative base excess value were significantly associated with in-hospital death.

Early Management of Severe Biliary Infection in the Era of the Tokyo Guidelines

Sepsis of biliary origin is increasing worldwide and has become one of the leading causes of emergency department admissions. The presence of multi-resistant bacteria (MRB) is increasing, and mortality rates may reach 20%. This review focuses on the changes induced by the Tokyo guidelines and new concepts related to the early treatment of severe biliary disease. If cholecystitis or cholangitis is suspected, ultrasound is the imaging test of choice. Appropriate empirical antibiotic treatment should be initiated promptly, and selection should be performed while bearing in mind the severity and risk factors for MRB. In acute cholecystitis, laparoscopic cholecystectomy is the main therapeutic intervention. In patients not suitable for surgery, percutaneous cholecystostomy is a valid alternative for controlling the infection. Treatment of severe acute cholangitis is based on endoscopic or transhepatic bile duct drainage and antibiotic therapy. Endoscopic ultrasound and other new endoscopic techniques have been added to the arsenal as novel alternatives in high-risk patients. However, biliary infections remain serious conditions that can lead to sepsis and death. The introduction of internationally accepted guidelines, based on clinical presentation, laboratory tests, and imaging, provides a framework for their rapid diagnosis and treatment. Prompt assessment of patient severity, timely initiation of antimicrobials, and early control of the source of infection are essential to reduce morbidity and mortality rates.

Safety and Efficacy of Ceftolozane/Tazobactam Plus Metronidazole Versus Meropenem From a Phase 2, Randomized Clinical Trial in Pediatric Participants With Complicated Intra-abdominal Infection

BACKGROUND

Ceftolozane/tazobactam, a cephalosporin-β-lactamase inhibitor combination, is approved for the treatment of complicated urinary tract infections and complicated intra-abdominal infections (cIAI). The safety and efficacy of ceftolozane/tazobactam in pediatric participants with cIAI were assessed.

METHODS

This phase 2 study (NCT03217136) randomized participants to either ceftolozane/tazobactam+metronidazole or meropenem for treatment of cIAI in pediatric participants (<18 years). The primary objective was to assess the safety and tolerability of intravenous ceftolozane/tazobactam+metronidazole. Clinical cure at end of treatment (EOT) and test of cure (TOC) visits were secondary end points.

RESULTS

The modified intent-to-treat (MITT) population included 91 participants (ceftolozane/tazobactam+metronidazole, n = 70; meropenem, n = 21). Complicated appendicitis was the most common diagnosis (93.4%); Escherichia coli was the most common pathogen (65.9%). Adverse events (AEs) occurred in 80.0% and 61.9% of participants receiving ceftolozane/tazobactam+metronidazole and meropenem, drug-related AEs occurred in 18.6% and 14.3% and serious AEs occurred in 11.4% and 0% of participants receiving ceftolozane/tazobactam+metronidazole and meropenem, respectively. No drug-related serious AEs or discontinuations due to drug-related AEs occurred. Rates of the clinical cure for ceftolozane/tazobactam+metronidazole and meropenem at EOT were 80.0% and 95.2% (difference: -14.3; 95% confidence interval: -26.67 to 4.93) and at TOC were 80.0% and 100.0% (difference: -19.1; 95% confidence interval: -30.18 to -2.89), respectively; 6 of the 14 clinical failures for ceftolozane/tazobactam+metronidazole at TOC were indeterminate responses imputed as failures per protocol.

CONCLUSION

Ceftolozane/tazobactam+metronidazole was well tolerated in pediatric participants with cIAI and had a safety profile similar to the established safety profile in adults. In this descriptive efficacy analysis, ceftolozane/tazobactam+metronidazole appeared efficacious.

Costo-efficacia di IMI/CIL/REL rispetto a CMS+IMI per il trattamento di infezioni batteriche Gram-negative non sensibili ai carbapenemi

Objective:

The objective of this analysis was to evaluate the cost-effectiveness of imipenem/cilastatin/relebactam compared to colistin-imipenem in the treatment of hospitalized patients with Gram-negative bacterial infections caused by imipenem-resistant pathogens. The perspective was both that of the National Health Service (NHS) and the social one.

Methodology:

A mixed model was developed to simulate a cohort of patients capable of highlighting the impacts of the disease on the quality of life and the absorption of economic resources of the patients in analysis. Modelled patients were those with hospital-acquired bacterial pneumonia/ventilator-associated bacterial pneumonia (HABP/VABP), complicated intra-abdominal infection (cIAI) or complicated urinal tract infection (cUTI) caused by carbapenem-resistant Gram-negative (GN) pathogens. The model begins with a short-term decision tree describing possible treatment routes and outcomes for patients during the hospitalization period. Patients who are healed in the decision tree enter the long-term Markov model, designed to capture the follow-up costs and health-related quality of life (HRQL) of patients healed over their lifetime.

Results:

The analysis, conducted on a hypothetical cohort of 1,000 patients, highlights how the use of imipenem/cilastatin/relebactam is advantageous both in terms of diagnosis and treatment in the short term and in terms of cost-effectiveness. In fact, it is dominant compared to colistin-imipenem both in the NHS and in the social perspective since, compared to an average saving of € 2,800.15 and € 3,174.63 respectively, it would generate an increase of 4.76 years of life and of 4.12 QALYs per patient.

A Focus on Intra-Abdominal Sepsis with Biomarkers: A Literature Review

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection according to the Third International Consensus Definitions for Sepsis and Septic Shock definitions. It is a clinical condition with high morbidity and mortality due to its complex pathophysiology and lack of a complete treatment. It constitutes a significant economic burden because it constitutes a substantial part of intensive care patients, and the treatment process is lengthy and costly. Therefore, early diagnosis and treatment of the disease are essential. After pneumonia, an essential source of sepsis is intra-abdominal infection. Due to the presence of multiple and polymicrobial sources of infection, abdominal sepsis progresses more seriously. The effective treatment of intra-abdominal infection consists of early recognition of the disease, control of the source, appropriate antibiotic therapy, and stabilization in the intensive care setting with an excellent surgical approach. We searched PubMed, EMBASE, MEDLINE, and the Cochrane Library. Two authors reviewed all identified abstracts and selected articles for full-text review. We included original studies assessing mediators in intraabdominal sepsis. Inflammatory and protein mediators such as acute phase protein and chemokine cytokines play an essential role in intra-abdominal sepsis. In clinical practice, white blood cell count, C-reactive protein, and procalcitonin are the most used parameters in the definition of abdominal infection. Tumor necrosis factor-alpha, interleukin-6, high-mobility group protein B1, and presepsin are other markers with high diagnostic efficiency, even though they are not used routinely. Despite everything, there is a need for highly effective markers that can be used in the diagnosis and follow-up of sepsis. Great hope is attached to these markers. This review aims to discuss the importance of the most used markers in the diagnosis and follow-up of abdominal sepsis and the markers on which there are essential studies in light of current literature.

A Proposal for a Classification Guiding the Selection of Appropriate Antibiotic Therapy for Intra-Abdominal Infections

Adequately controlling the source of infection and prescribing appropriately antibiotic therapy are the cornerstones of the management of patients with intra-abdominal infections (IAIs). Correctly classifying patients with IAIs is crucial to assessing the severity of their clinical condition and deciding the strategy of the treatment, including a correct empiric antibiotic therapy. Best practices in prescribing antibiotics may impact patient outcomes and the cost of treatment, as well as the risk of “opportunistic” infections such as Clostridioides difficile infection and the development and spread of antimicrobial resistance. This review aims to identify a correct classification of IAIs, guiding clinicians in the selection of the best antibiotic therapy in patients with IAIs.

Antimicrobial Challenge in Acute Care Surgery

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients' morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.

The efficacy and safety of eravacycline compared with current clinically common antibiotics in the treatment of adults with complicated intra-abdominal infections: A Bayesian network meta-analysis

Background

Eravacycline is a novel, fully synthetic fluorocycline antibiotic for the treatment of adults with complicated intra-abdominal infections (cIAIs). However, the efficacy and safety of eravacycline compared with current clinically common antibiotics remain unknown.

Objective

This study aims to compare the efficacy and safety of eravacycline and other clinically common antibiotics in China, including tigecycline, meropenem, ertapenem, ceftazidime/avibactam+metronidazole, piperacillin/tazobactam, imipenem/cilastatin, and ceftriaxone+metronidazole, for the treatment of adults with cIAIs and to provide a reference for clinical choice.

Methods

The PubMed, Embase, Cochrane Library, and ClinicalTrials.gov databases were electronically searched to collect clinical randomized controlled studies (RCTs) comparing different antibiotics in the treatment of patients with cIAIs from inception to June 1, 2021. Two reviewers independently screened the literature, extracted data, and evaluated the risk of bias in the included studies.

Results

A total of 4050 articles were initially retrieved, and 25 RCTs were included after screening, involving eight treatment therapies and 9372 patients. The results of network meta-analysis showed that in the intention-to-treat (ITT) population, the clinically evaluable (CE) population, and the microbiologically evaluable (ME) population, the clinical response rate of eravacycline was not significantly different from that of the other 7 therapies (P > 0.05). In terms of microbiological response rate, eravacycline was significantly better than tigecycline [tigecycline vs. eravacycline: RR = 0.82, 95%CI (0.65,0.99)], and there was no significant difference between the other 6 regimens and eravacycline (P > 0.05). In terms of safety, the incidence of serious adverse events, discontinuation rate, and all-cause mortality of eravacycline were not significantly different from those of the other 7 treatment therapies (P > 0.05).

Conclusion

Based on the evidence generated by the current noninferiority clinical trial design, the efficacy and safety of eravacycline for the treatment of adults with cIAIs are not significantly different from those of the other 7 commonly used clinical antibiotics in China. In terms of microbiological response rate, eravacycline was significantly better than tigecycline. In view of the severe multidrug-resistant situation in China, existing drugs have difficulty meeting the needs of clinical treatment, and the new antibacterial drug eravacycline may be one of the preferred options for the treatment of cIAIs in adults.

The 2021 Dutch Working Party on Antibiotic Policy (SWAB) guidelines for empirical antibacterial therapy of sepsis in adults

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.

Comparison of the PIPAS severity score tool and the QSOFA criteria for predicting in-hospital mortality of peritonitis in a tertiary hospital in Uganda: a prospective cohort study

BACKGROUND

The majority of the prognostic scoring tools for peritonitis are impractical in low resource settings because they are complex while others are quite costly. The quick Sepsis-related Organ Failure Assessment (qSOFA) score and the Physiologic Indicators for Prognosis in Abdominal Sepsis (PIPAS) severity score are two strictly bedside prognostic tools but their predictive ability for mortality of peritonitis is yet to be compared. We compared the predictive ability of the qSOFA criteria and the PIPAS severity score for in-hospital mortality of peritonitis.

METHOD

This was a prospective cohort study on consecutive peritonitis cases managed surgically in a tertiary hospital in Uganda between October 2020 to June 2021. PIPAS severity score and qSOFA score were assessed preoperatively for each case and all cases were then followed up intra- and postoperatively until discharge from the hospital, or up to 30 days if the in-hospital stay was prolonged; the outcome of interest was in-hospital mortality. We used Receiver Operating Characteristic curve analysis to assess and compare the predictive abilities of these two tools for peritonitis in-hospital mortality. All tests were 2 sided (p < 0.05) with 95% confidence intervals.

RESULTS

We evaluated 136 peritonitis cases. Their mean age was 34.4 years (standard deviation = 14.5). The male to female ratio was 3:1. The overall in-hospital mortality rate for peritonitis was 12.5%. The PIPAS severity score had a significantly better discriminative ability (AUC = 0.893, 95% CI 0.801-0.986) than the qSOFA score (AUC = 0.770, 95% CI 0.620-0.920) for peritonitis mortality (p = 0.0443). The best PIPAS severity cut-off score (a score of > = 2) had sensitivity and specificity of 76.5%, and 93.3% respectively, while the corresponding values for the qSOFA criteria (score > = 2), were 58.8% and 98.3% respectively.

CONCLUSIONS

The in-hospital mortality in this cohort of peritonitis cases was high. The PIPAS severity score tool has a superior predictive ability and higher sensitivity for peritonitis in-hospital mortality than the qSOFA score tool although the latter tool is more specific. We recommend the use of the PIPAS severity score as the initial prognostic tool for peritonitis cases in the emergency department.

Vacuum-assisted closure versus on-demand relaparotomy in patients with secondary peritonitis-the VACOR trial: protocol for a randomised controlled trial

BACKGROUND

Secondary peritonitis is a severe condition with a 20-32% reported mortality. The accepted treatment modalities are vacuum-assisted closure (VAC) or primary closure with relaparotomy on-demand (ROD). However, no randomised controlled trial has been completed to compare the two methods potential benefits and disadvantages.

METHODS

This study will be a randomised controlled multicentre trial, including patients aged 18 years or older with purulent or faecal peritonitis confined to at least two of the four abdominal quadrants originating from the small intestine, colon, or rectum. Randomisation will be web-based to either primary closure with ROD or VAC in blocks of 2, 4, and 6. The primary endpoint is peritonitis-related complications within 30 or 90 days and one year after index operation. Secondary outcomes are comprehensive complication index (CCI) and mortality after 30 or 90 days and one year; quality of life assessment by (SF-36) after three and 12 months, the development of incisional hernia after 12 months assessed by clinical examination and CT-scanning and healthcare resource utilisation. With an estimated superiority of 15% in the primary outcome for VAC, 340 patients must be included. Hospitals in Denmark and Europe will be invited to participate.

DISCUSSION

There is no robust evidence for choosing either open abdomen with VAC treatment or primary closure with relaparotomy on-demand in patients with secondary peritonitis. The present study has the potential to answer this important clinical question.

TRIAL REGISTRATION

The study protocol has been registered at clinicaltrials.gov (NCT03932461). Protocol version 1.0, 9 January 2022.

The Role of Abdominal Drain Cultures in Managing Abdominal Infections

Intra-abdominal infections (IAI) are common in hospitalized patients, both in and outside of the intensive care unit. Management principles include antimicrobial therapy and source control. Typically, these infections are polymicrobial, and intra-operative samples will guide the targeted antimicrobial therapy. Although the use of prophylactic abdominal drains in patients undergoing abdominal surgery is decreasing, the use of drains to treat IAI, both in surgical and non-surgical strategies for abdominal infection, is increasing. In this context, samples from abdominal drains are often used to assist in antimicrobial decision making. In this narrative review, we provide an overview of the current role of abdominal drains in surgery, discuss the importance of biofilm formation in abdominal drains and the mechanisms involved, and review the clinical data on the use of sampling these drains for diagnostic purposes. We conclude that biofilm formation and the colonization of abdominal drains is common, which precludes the use of abdominal fluid to reliably diagnose IAI and identify the pathogens involved. We recommend limiting the use of drains and, when present, avoiding routine microbiological sampling.

Effect of Antibiotic Duration in Emergency General Surgery Patients with Intra-Abdominal Infection Managed with Open vs Closed Abdomen

BACKGROUND

Data on duration of antibiotics in patients managed with an open abdomen (OA) due to intra-abdominal infection (IAI) are scarce. We hypothesized that patients with IAI managed with OA rather than closed abdomen (CA) would have higher rates of secondary infections (SIs) independent of the duration of the antibiotic treatment.

METHODS

This was an observational, prospective, multicenter, international study of patients with IAI requiring laparotomy for source control. Demographic and antibiotic duration values were collected. Primary outcomes were SI (surgical site, bloodstream, pneumonia, urinary tract) and mortality. Statistical analysis included ANOVA, chi-square/Fisher's exact test, and logistic regression.

RESULTS

Twenty-one centers contributed 752 patients. The average age was 59.6 years, 43.6% were women, and 43.9% were managed with OA. Overall mortality was 16.1%, with higher rates among OA patients (31.6% vs 4.4%, p < 0.001). OA patients had higher Sequential Organ Failure Assessment (4.7 vs 1.8, p < 0.001), American Society of Anesthesiologists Physical Status (3.6 vs 2.7, p < 0.001), and APACHE II scores (16.1 vs 9.4, p < 0.001). The mean duration of antibiotics was 6.5 days (8.0 OA vs 5.4 CA, p < 0.001). A total of 179 (23.8%) patients developed SI (33.1% OA vs 16.8% CA, p < 0.001). Longer antibiotic duration was associated with increased rates of SI: 1 to 2 days, 15.8%; 3 to 5 days, 20.4%; 6 to 14 days, 26.6%; and more than 14 days, 46.8% (p < 0.001).

CONCLUSIONS

Patients with IAI managed with OA had higher rates of SI and increased mortality compared with CA. A prolonged duration of antibiotics was associated with increased rates of SI. Increased antibiotic duration is not associated with improved outcomes in patients with IAI and OA.

Cefepime Dosing Requirements in Elderly Patients Attended in the Emergency Rooms

Objective

This study aimed to assess the probability of reaching an adequate pharmacokinetic/pharmacodynamic (pK/pD) index for different cefepime dosages in frail patients with bacteremia treated in the emergency room.

Methods

Simulation study based on Gram-negative bacterial strains that cause bacteremia. The probability of reaching a time above the minimum inhibitory concentration (MIC) at 50% and 100% dosing intervals (fT > 50 and fT > 80% MIC) was assessed for two different renal clearance intervals.

Results

One hundred twenty nine strains were collected, the predominant species being Escherichia coli (n = 83 [64.3%]). In patients with a ClCr of 30 mL/min, an fT > 50% MIC was reached in more than 90% of the simulations. However, a dose of at least 1 g every 12 h must be administered to reach an fT > 80% MIC. In patients with a ClCr of 30–60 mL/min, the probability of reaching an fT > 50% MIC was higher than 90% with doses of 1 g every 8 h or more, but this value was not reached in > 90% simulations for any of the doses tested in this study.

Conclusions

Standard cefepime dosing can reach an adequate PK/PD index in frail patients. Nevertheless, a high dose or extended infusion is necessary to reach an fT > 80% MIC in patients with a ClCr > 60 mL/min.

Risk Factors for Mortality in Abdominal Infection Patients in ICU: A Retrospective Study From 2011 to 2018

To identify the risk factors related to the patient's 28-day mortality, we retrospectively reviewed the records of patients with intra-abdominal infections admitted to the ICU of Nanfang Hospital, Southern Medical University from 2011 to 2018. Multivariate Cox proportional hazard regression analysis was used to identify independent risk factors for mortality. Four hundred and thirty-one patients with intra-abdominal infections were analyzed in the study. The 28-day mortality stepwise increased with greater severity of disease expression: 3.5% in infected patients without sepsis, 7.6% in septic patients, and 30.9% in patients with septic shock (p &lt; 0.001). In multivariate analysis, independent risk factors for 28-day mortality were underlying chronic diseases (adjusted HR 3.137, 95% CI 1.425–6.906), high Sequential Organ Failure Assessment (SOFA) score (adjusted HR 1.285, 95% CI 1.160–1.424), low hematocrit (adjusted HR 1.099, 95% CI 1.042–1.161), and receiving more fluid within 72 h (adjusted HR 1.028, 95% CI 1.015–1.041). Compared to the first and last 4 years, the early use of antibiotics, the optimization of IAT strategies, and the restriction of positive fluid balance were related to the decline in mortality of IAIs in the later period. Therefore, underlying chronic diseases, high SOFA score, low hematocrit, and receiving more fluid within 72 h after ICU admission were independent risk factors for patients' poor prognosis.

Intra-abdominal Infections

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.

Rate of stoma formation following damage-control surgery for severe intra-abdominal sepsis: a single-centre consecutive case series

BACKGROUND

Severe intra-abdominal sepsis (IAS) is associated with high mortality and stoma rates. A two-stage approach with initial damage-control surgery (DCS) and subsequent reconstruction might decrease stoma and mortality rates but requires standardization.

METHODS

A standardized two-stage damage-control algorithm for IAS was implemented in April 2016 and applied systematically.

RESULTS

Some 203 consecutive patients (median age 70 years, 62 per cent ASA score greater than 3) had DCS for severe IAS. Median operation time was 82 minutes, 60 per cent performed during night-time. Median intraoperative noradrenaline doses were 20 (i.q.r. 26) µg/min and blood gas analysis (ABG) was abnormal (metabolic acidosis) in 90 per cent of patients. The second-stage operation allowed definitive surgery in 76 per cent of patients, 24 per cent had up to four re-DCSs until definitive surgery. The in-hospital mortality rate was 26 per cent. At hospital discharge, 65 per cent of patients were stoma free. Risk factors for in-hospital death were noradrenaline (odds ratio 4.25 (95 per cent c.i. 1.72 to 12.83)), abnormal ABG (pH: odds ratio 2.72 (1.24 to 6.65); lactate: odds ratio 6.77 (3.20 to 15.78)), male gender (odds ratio 2.40 (1.24 to 4.85)), ASA score greater than 3 (odds ratio 5.75 (2.58 to 14.68)), mesenteric ischaemia (odds ratio 3.27 (1.71 to 6.46)) and type of resection (odds ratio 2.95 (1.24 to 8.21)). Risk factors for stoma at discharge were ASA score greater than 3 (odds ratio 2.76 (95 per cent c.i. 1.38 to 5.73)), type of resection (odds ratio 30.91 (6.29 to 559.3)) and longer operation time (odds ratio 2.441 (1.22 to 5.06)).

CONCLUSION

Initial DCS followed by secondary reconstruction of bowel continuity for IAS within 48 hours in a tertiary teaching hospital was feasible and safe, following a clear algorithm.

Advances in the pharmacological management of bacterial peritonitis

Introduction: Bacterial peritonitis is an infection with high mortality if not treated immediately. In the absence of an intraabdominal source of infection, bacterial peritonitis may arise in patients with liver cirrhosis, in patients on peritoneal dialysis (PD) for end-stage renal disease or in patients with tuberculosis. In patients with cirrhosis, bacterial peritonitis may trigger acute on chronic liver failure with substantial mortality despite optimal treatment. In patients on PD, peritonitis may make continuation of PD impossible, necessitating the switch to hemodialysis.Areas covered: Recovery from peritonitis and prevention of complications depend on timely pharmacological management. Challenges are the broad microbiological spectrum with growing rates of antimicrobial resistance, the underlying chronic liver or kidney failure and high rates of relapse. The authors provide a review of predisposing conditions, diagnosis, and prevention of bacterial peritonitis with a particular focus on the pharmacological management.Expert opinion: Diagnosis of the type of bacterial peritonitis is essential to pharmacological management. In patients with spontaneous bacterial peritonitis, broad-spectrum antibiotics should be given intravenously in conjunction with albumin. In patients on PD, antibiotic therapy should be preferably applied intraperitoneally with empirical coverage of gram-positive and gram-negative bacteria. Secondary peritonitis usually requires surgical or interventional treatment.

Geographic Shifts in Antibacterial Drug Clinical Trial Enrollment: Implications for Generalizability

BACKGROUND

As drug development has globalized, trials have increasingly enrolled participants from all parts of the world rather than just the United States and Western Europe. For antibacterial drug trials, understanding enrollment trends and regional differences is important for generalizability considerations.

METHODS

We retrospectively analyzed 42 phase 3 trials submitted to the US Food and Drug Administration after 2001 for complicated urinary tract infection (cUTI), complicated intra-abdominal infection (cIAI), community-acquired bacterial pneumonia (CABP), and acute bacterial skin and skin structure infection (ABSSSI) (n = 29 282 participants). Enrollment numbers, demographics, clinical characteristics, and microbiological data were compared to identify temporal and geographic trends.

RESULTS

For cUTI, cIAI, and CABP trials, Eastern European enrollment greatly increased over the study period. For ABSSSI trials, North American enrollment increased. Demographic characteristics and regional microbiology among regions were broadly similar with several exceptions. For cIAI trials, Eastern European participants had the lowest proportion of participants with prior antibacterial drug therapy. For ABSSSI trials, North American participants more commonly reported intravenous drug use. Microbiological differences relative to North America included a greater proportion of Klebsiella pneumoniae among Asian cIAI isolates (17.8% vs 9.0%, P = .0057), a higher proportion of cephalosporin resistance in South American Enterobacteriaceae cUTI isolates (26.8% vs 15.7%, P = .044), and a lower proportion of Staphylococcus aureus in Eastern European ABSSSI isolates (43.7% vs 61.9%, P < .0001).

CONCLUSIONS

Geographic trends in recruitment for recent antibacterial clinical trials differ by indication. Regional similarities in demographic characteristics and microbiology across regions lessen concerns regarding generalizability due to shifting enrollment trends.

The Efficacy of Posttreatment with Synthetic C-Reactive Protein in Murine Bacterial Peritonitis via Activation of FcγRI-Expressing Kupffer Cells

Pretreatment with synthetic C-reactive protein (CRP), a functional CRP peptide, has the potential to augment macrophage phagocytosis by bacterial challenge. However, the posttreatment is clinically ideal. We investigated the efficacy of posttreatment with synthetic CRP on murine cecal ligation and puncture (CLP), focusing on liver macrophages. Mice received CLP, and 1 h later, synthetic CRP or saline was intraperitoneally administered. Posttreatment with synthetic CRP increased the murine survival after CLP. It reduced viable bacterial counts in the liver 24 h after CLP with an increase in the number of Kupffer cells but not monocyte-derived liver macrophages. Posttreatment with synthetic CRP increased the phagolytic activity of Kupffer cells against Escherichia coli (E. coli) as well as capsulated Klebsiella pneumoniae at 3 h after CLP. Synthetic CRP therapy augmented TNF production by E. coli-phagocytosing Kupffer cells, resulting in an increase in tissue TNF levels in the liver at 24 h. Kupffer cells substantially expressed FcγRI, which is a ligand of CRP, and their FcγRI expression was further increased after CLP. In contrast, synthetic CRP therapy affected neither the phagocytic function of monocyte-derived liver macrophages (showing a weak FcγRI expression) nor their TNF production. Depletion of Kupffer cells in mice inhibited these beneficial effects of synthetic CRP in CLP mice. Conclusion: Posttreatment with synthetic CRP effectively improves murine bacterial peritonitis via the activation of phagocytosis of FcγRI-expressing Kupffer cells.

Predictive value of immune cell counts and neutrophil-to-lymphocyte ratio for 28-day mortality in patients with sepsis caused by intra-abdominal infection

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.

Risk Factors for Enterococcal Intra-Abdominal Infections and Outcomes in Intensive Care Unit Patients

Background: To investigate the risk factors for enterococcal intra-abdominal infections (EIAIs) and the association between EIAIs and outcomes in intensive care unit (ICU) patients. Methods: We reviewed retrospectively the records of patients with intra-abdominal infections admitted to the Department of Critical Care Medicine at Nanfang Hospital, Southern Medical University, China, from January 2011 to December 2018. Patients with intra-abdominal infections were divided into enterococcal and non-enterococcal groups based on whether enterococci were isolated from intra-abdominal specimens. Results: A total of 431 patients with intra-abdominal infections were included, of whom 119 were infected with enterococci and 312 were infected with non-enterococci. Enterococci were isolated in 27.6% of patients, accounting for 24.5% (129/527) of all clinical bacterial isolates. Post-operative abdominal infection (adjusted odds ratio [OR], 2.361; p = 0.004), intestinal infection (adjusted OR, 2.703; p < 0.001), Mannheim Peritonitis Index score (MPI; adjusted OR, 1.052; p = 0.015), and use of antibiotic agents within the previous 90 days (adjusted OR, 1.880; p = 0.025) were associated with an increased risk of EIAIs. Compared with patients without enterococcal infection, ICU patients with enterococcal infection had a higher risk of failure of initial clinical therapy (49.6% vs. 24.2%; p < 0.001) and longer hospital stays (33 days [19, 48] vs. 18 days [12, 29]; p < 0.001). Enterococcal infection was associated with increased 28-day mortality, in-hospital mortality, and ICU mortality. However, no difference was found in length of ICU stay between the two groups. Additionally, there was no difference in ICU mortality, hospital mortality, or 28-day mortality in patients infected with enterococcus who did or did not receive empirical anti-enterococcal therapy. Conclusion: Post-operative abdominal infection, intestinal infection, MPI score, and use of antibiotic agents within the previous 90 days were independent risk factors for enterococcal infection. Enterococcal infection was associated with reduced short-term survival in ICU patients.

Impact of an Acute Care Surgery Model on the Management of Acute Appendicitis in South Korea: A Retrospective Cohort Study

Background

The acute care surgery (ACS) system is a new model for the prompt management of diseases that require rapid treatment in patients with acute abdomen. This study compared the outcomes and characteristics of the ACS system and traditional on-call system (TROS) for acute appendicitis in South Korea.

Methods

This single-center, retrospective study included all patients (aged ≥18 years) who underwent surgery for acute appendicitis in 2016 and 2018. The TROS and ACS system were used for the 2016 and 2018 groups, respectively. We retrospectively obtained data on each patient from the electrical medical records. The independent samples t-test and Mann-Whitney U-test were used for continuous and nonnormally distributed data, respectively.

Results

In total, 126 patients were included. The time taken to get from the emergency room admission to the operating room, operation times, and postoperative complication rates were similar between both groups. However, the length of the hospital stay was shorter in the ACS group than in the TROS group (4.3 ± 3.2 days vs. 7.2 ± 9.6 days, p=0.039).

Conclusions

Since the introduction of the ACS system, the length of hospital stay for surgical patients has decreased. This may be due to the application of an integrated medical procedure, such as a new clinical pathway, rather than differences in the surgical techniques.

Impact of the COVID-19 pandemic lockdown on the utilization of acute surgical care in the State of Salzburg, Austria: retrospective, multicenter analysis

Background

Some medical disciplines have reported a strong decrease of emergencies during the coronavirus disease 2019 (COVID-19) pandemic; however, the effect of the lockdown on general surgery emergencies remains unclear.

Methods

This study is a retrospective, multicenter analysis of general surgery emergency operations performed during the period from 1 March to 15th 2020 lockdown and in the same time period of 2019 in three medical centers providing emergency surgical care to the area Salzburg-North, Austria.

Results

In total 165 emergency surgeries were performed in the study period of 2020 compared to 287 in 2019. This is a significant decrease of 122 (42.5%) emergency surgeries during the COVID-19 lockdown (p = 0.005). The length of hospital stay was reduced to 3 days in 2020 compared to 4 in 2019. Appendectomy remained the most performed emergency surgery for both periods; however the number of surgeries was reduced to less than a half, with 72 cases in 2019 and 33 cases in 2020 (p = 0.118). Emergency colon surgery observed the strongest decrease of 75% from 17 cases in 2019 to 4 in 2020. In addition, the emergency abdominal wall hernia, cholecystectomies for acute cholecystitis, small surgeries and proctological emergencies recorded drops of 70%, 39%, 33% and 47% respectively. The strongest reduction in frequencies of emergency surgeries was reported from the designated COVID center in the examined region.

Conclusions

Emergency general surgery is an essential service that continues to run under all circumstances. Our data show that COVID-19-related restrictions have resulted in a significant decrease in the utilization of acute surgical care.

Diagnosis and Management of Intraabdominal Infection: Guidelines by the Chinese Society of Surgical Infection and Intensive Care and the Chinese College of Gastrointestinal Fistula Surgeons

The Chinese guidelines for IAI presented here were developed by a panel that included experts from the fields of surgery, critical care, microbiology, infection control, pharmacology, and evidence-based medicine. All questions were structured in population, intervention, comparison, and outcomes format, and evidence profiles were generated. Recommendations were generated following the principles of the Grading of Recommendations Assessment, Development, and Evaluation system or Best Practice Statement (BPS), when applicable. The final guidelines include 45 graded recommendations and 17 BPSs, including the classification of disease severity, diagnosis, source control, antimicrobial therapy, microbiologic evaluation, nutritional therapy, other supportive therapies, diagnosis and management of specific IAIs, and recognition and management of source control failure. Recommendations on fluid resuscitation and organ support therapy could not be formulated and thus were not included. Accordingly, additional high-quality clinical studies should be performed in the future to address the clinicians' concerns.

Current progress of source control in the management of intra-abdominal infections

Intra-abdominal infection (IAI) is a deadly condition in which the outcome is associated with urgent diagnosis, assessment and management, including fluid resuscitation, antibiotic administration while obtaining further laboratory results, attaining precise measurements of hemodynamic status, and pursuing source control. This last item makes abdominal sepsis a unique treatment challenge. Delayed or inadequate source control is an independent predictor of poor outcomes and recognizing source control failure is often difficult or impossible. Further complicating issue in the debate is surrounding the timing, adequacy, and procedures of source control. This review evaluated and summarized the current approach and challenges in IAI management, which are the future research directions.

2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis

BACKGROUND

Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.

MATERIALS AND METHODS

The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.

RESULTS

The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.

CONCLUSIONS, KNOWLEDGE GAPS AND RESEARCH RECOMMENDATIONS

ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.

Therapeutic Effects of Hyaluronic Acid in Peritonitis-Induced Sepsis in Mice

Intra-abdominal infection is the second most common cause of sepsis, and the mortality rate from abdominal sepsis remains high. High molecular weight (HMW) hyaluronic acid (HA) has been studied in sterile injury models as an anti-inflammatory and anti-permeability agent. This study evaluated the therapeutic effects of intraperitoneal HMW HA administration in mice with peritonitis-induced sepsis. Sepsis was induced in C57BL/6 mice by cecal ligation and puncture (CLP), followed 4 h later by an intraperitoneal injection of HMW HA (20 mg/kg) solution or phosphate buffered saline (PBS). Survival, physiological data, organ injury, bacterial burden, and inflammatory cytokine levels were assessed in the CLP mice. To assess the effect of HA on macrophage phagocytosis activity, RAW264.7 cells, primed with lipopolysaccharide, were exposed with either PBS or HMW HA (500 μg/mL) prior to exposure to 10 CFU of E coli bacteria. HMW HA instillation significantly improved blood oxygenation, lung histology, and survival in CLP mice. Inflammatory cytokine levels in the plasma and bacterial burdens in the lung and spleen were significantly decreased by HA administration at 24 h after CLP. At 6 h after CLP, HA significantly decreased bacterial burden in the peritoneal lavage fluid. HMW HA administration significantly increased E coli bacterial phagocytosis by RAW264.7 cells in part through increased phosphorylation of ezrin/radixin/moesin, a known downstream target of CD44 (a HA receptor); ezrin inhibition abolished the enhanced phagocytosis by RAW264.7 cells induced by HA. Intraperitoneal administration of HMW HA had therapeutic effects against CLP-induced sepsis in terms of suppressing inflammation and increasing antimicrobial activity.

Emerging Spectrum of Perforation Peritonitis in Developing World

Background: Gastrointestinal perforations constitute a major cause of patients with acute abdomen pain coming to the surgery emergency room. Incidence, site of perforation, and age is different in the developing world and is showing new trends. The etiological spectrum in the developing world is different from the western world. This study was conducted to find out the latest trends in perforation peritonitis in India. Methods: This study was conducted in a single surgical unit of Darbhanga Medical College and Hospital, India. A total of 350 consecutive patients with perforation peritonitis were studied in terms of age, sex, seasonal variation, biochemical parameters, clinical presentation, radiological and intraoperative findings, surgical intervention, and postoperative outcome. Results: The most common cause of perforation peritonitis in our study was a duodenal ulcer (~50%) followed by typhoid (20%), traumatic (14.5%), appendicular (7.4%), and tubercular (3.1%) cases. Males were three times more commonly affected than females. Peak incidence was noted in the 2^nd and 3^rd decades of life. Peptic ulcer perforations were common in autumn and winter and typhoid perforations were common during the summer and rainy seasons. Conclusion: Spectrum of perforation peritonitis cases in this part of world is different from developed western countries. It is different in respect of younger age at presentation, site of perforation, and etiological factors. Infective pathology makes up to a quarter of total cases in the developing world. The developing world has more perforation peritonitis cases involving the upper gastrointestinal tract, while the western world has a predominance of lower gastrointestinal tract perforations.

Mortality After General Surgery Among Hospitalized Patients With Hematologic Malignancy

BACKGROUND

Hospitalized patients with hematologic malignancies (HMs) may require abdominal operations for complications of malignancy, treatment sequelae, or unrelated abdominal pathology. We determined predictors of mortality after emergency general surgery for patients with HM using national-level data.

MATERIALS AND METHODS

We analyzed the 2010-2014 National Inpatient Sample for International Classification of Disease, Ninth Revision, Clinical Modification codes for HM and abdominal operations, comparing adult patient encounters with abdominal operations with HM to those without HM. Multivariate logistic regression was performed to identify predictors of mortality.

RESULTS

Of the 7.9 million adult inpatient encounters where abdominal surgery was performed, 82,187 (1%) had concomitant diagnoses of HM. Mortality among patient encounters with HM was significantly higher than without HM (9.0% versus 2.0%; P < 0.0001). Patient encounters with HM and surgery and a diagnosis of acute abdominal pain had mortality rates as high as 41%. The median standardized risk ratio for death after the top 25 general surgery procedures was 2.9 (interquartile range: 2.2-3.8) among patients with HM. In adjusted analyses, odds of mortality among patients with HM undergoing surgery were increased by concomitant acute abdominal pain diagnosis (odds ratio [OR] = 2.6; P < 0.0001), coagulopathy (OR = 2.0; P < 0.0001), aplastic anemia (OR = 1.7; P < 0.0001), peripheral vascular disease (OR = 1.4; P = 0.001), and weight loss (OR = 1.3; P < 0.0001).

CONCLUSIONS

Although uncommon, surgery on patients with HM is associated with mortality rates nearly five times higher than the general surgical population. Patients with HM requiring surgical intervention may be at particularly high odds of death and postoperative complications.

Antimicrobial Spectrum of Titroleane™: A New Potent Anti-Infective Agent

Tea Tree oil (TTO) is well known for its numerous good properties but might be also irritating or toxic when used topically or ingested, thus limiting the number of possible applications in Humans. The aim of the study was to characterize the antimicrobial spectrum as well as the toxicity of Titroleane™, a new anti-infective agent obtained from TTO but cleared of its toxic monoterpenes part. The susceptibility to Titroleane™ of various pathogens (bacteria and fungi) encountered in animal and human health was studied in comparison with that of TTO. Antimicrobial screening was carried out using the broth microdilution method. Activities against aerobic, anaerobic, fastidious and non-fastidious microorganisms were performed. For all microorganisms tested, the MIC values for Titroleane™ ranged from 0.08% to 2.5%, except for Campylobacter jejuni, and Aspergillus niger. In particular, Titroleane™ showed good efficacy against skin and soft tissue infection pathogens, such as methicillin resistant Staphylococcus aureus (MRSA), intra-abdominal infections and oral pathogens, as well as fish farming pathogens. Toxicity testing showed little and similar cytotoxicities between TTO and Titroleane™ of 37% and 23%, respectively at a concentration of 0.025% (v/v). Finally, we demonstrated that the antimicrobial activity of Titroleane™ is similar to that of TTO.

[Laparoscopic surgery for advanced appendicular peritonitis]

OBJECTIVE

To evaluate the results of laparoscopic treatment of patients with advanced appendicular peritonitis.

MATERIAL AND METHODS

There were 271 patients with acute appendicitis complicated by peritonitis. The main group consisted of patients who underwent laparoscopic appendectomy after diagnostic laparoscopy (n=231), the control group - diagnostic laparoscopy followed by conversion to median laparotomy (n=36). Four extremely ill patients were operated through laparotomy and excluded from the further analysis.

RESULTS

Diagnostic laparoscopy was performed in 267 patients with advanced appendicular peritonitis. Laparoscopic appendectomy, debridement and abdominal drainage were performed in 231 (85.2%) patients. Mean age of patients was 44±18.5 years, duration of disease - 36.2±20.3 hours. Diffuse peritonitis was diagnosed in 219 (82%) patients, advanced peritonitis - in 48 (16.5%) cases. Incidence of conversion was 13.5%. Mortality was absent in both groups. Postoperative morbidity was significantly higher in the conversion group (72.2% vs. 29.4%, p<0.0001).

CONCLUSION

Laparoscopic interventions for common appendicular peritonitis are feasible, effective and reduce postoperative morbidity.

Systematic Review and Meta-Analysis of the Efficacy of Appropriate Empiric Anti-Enterococcal Therapy for Intra-Abdominal Infection

Background: Delayed treatment of seriously infected patients results in increased mortality. However, antimicrobial therapy for the initial 24 to 48 hours is mostly empirically provided, without evidence regarding the causative pathogen. Whether empiric anti-enterococcal therapy should be administered to treat intra-abdominal infection (IAI) before obtaining culture results remains unknown. We performed a meta-analysis to explore the effects of empiric enterococci covered antibiotic therapy in IAI and the risk factors for enterococcal infection in IAI. Methods: We searched multiple databases systematically and included 23 randomized controlled trials (RCTs) and 13 observational studies. The quality of included studies was assessed, and the reporting bias was evaluated. Meta-analysis was performed using random effects or fixed effects models according to the heterogeneity. The risk ratio (RR), odds ratio (OR), and 95% confidence interval (CI) were calculated. Results: Enterococci-covered antibiotic regimens provided no improvement in treatment success compared with control regimens (RR, 0.99; 95% CI, 0.97-1.00; p = 0.15), with similar mortality and adverse effects in both arms. Basic characteristic analysis revealed that most of the enrolled patients with IAI in RCTs were young, lower risk community-acquired intra-abdominal infection (CA-IAI) patients with a relatively low APACHE II score. Interestingly, risk factor screening revealed that malignancy, corticosteroid use, operation, any antibiotic treatment, admission to intensive care unit (ICU), and indwelling urinary catheter could predispose the patients with IAI to a substantially higher risk of enterococcal infection. "Hospital acquired" itself was a risk factor (OR, 2.81; 95% CI, 2.34-3.39; p < 0.001). Conclusion: It is unnecessary to use additional agents empirically to specifically provide anti-enterococcal coverage for the management of CA-IAI in lower risk patients without evidence of causative pathogen, and risk factors can increase the risk of enterococcal infection. Thus, there is a rationale for providing empiric anti-enterococcal coverage for severely ill patients with CA-IAI with high risk factors and patients with hospital-acquired intra-abdominal infection (HA-IAI).

Shorter Total Length of Stay After Intraperitoneal Fosfomycin, Metronidazole, and Molgramostim for Complicated Appendicitis: A Pivotal Quasi-Randomized Controlled Trial

Background: We aimed to investigate the difference in the total length of hospital stay (LOS) after intraperitoneal vs. intravenous antibiotic treatment in patients with complicated appendicitis.

Methods: We conducted a quasi-randomized prospective clinical trial. The intervention group received 4 g fosfomycin, 1 g metronidazole, and 50 μg recombinant human granulocyte-macrophage colony-stimulating factor intraperitoneally, which was left in the abdominal cavity, immediately after laparoscopic appendectomy. Postoperatively, this group received antibiotics orally. The control group received intravenous antibiotics both during surgery and postoperatively. We primarily evaluated total LOS within 30 days. Furthermore, we evaluated harms and adverse events, Gastrointestinal Quality of Life Index, postoperative complications, and convalescence. Participants were followed for 30 days postoperatively.

Results: A total of 12 participants concluded the trial. The total LOS was significantly shorter in the intervention group (six participants, median 13 h; range 2–21 h) than in the control group (six participants, median 84 h; range 67–169 h), p = 0.017. Comparable harms and Gastrointestinal Quality of Life Index scores were found in the two groups. The time to return to normal activities was median 6 and 10 days for the intervention and the control group, respectively. There were no serious adverse events related to the trial nor any complications in the intervention group. In the control group, two patients developed intraabdominal abscesses.

Conclusions: The intervention group had a significantly shorter total LOS. The study was not powered to assess differences in complications, but the results indicate that the intervention seems to be a safe regimen, which can be investigated further to treat patients with complicated appendicitis.

Identifiers: EudraCT no. 2017-004753-16.

ClinicalTrials:https://clinicaltrials.gov/ct2/show/NCT03435900?term=NCT03435900&draw=2&rank=1">draw=2&rank=1.

The Bucharest ESTES consensus statement on peritonitis

INTRODUCTION

Peritonitis is still an important health problem associated with high morbidity and mortality. A multidisciplinary approach to the management of patients with peritonitis may be an important factor to reduce the risks for patients and improve efficiency, outcome, and the cost of care.

METHODS

Expert panel discussion on Peritonitis was held in Bucharest on May 2017, during the 17th ECTES Congress, involving surgeons, infectious disease specialists, radiologists and intensivists with the goal of defining recommendations for the optimal management of peritonitis.

CONCLUSION

This document is an updated presentation of management of peritonitis and represents the summary of the final recommendations approved by a panel of experts.

[Comparison of laparoscopic and open suturing of perforated peptic ulcer complicated by advanced peritonitis]

AIM

To compare the results of open and laparoscopic interventions for PGDU complicated by advanced peritonitis.

MATERIAL AND METHODS

A retrospective analysis enrolled 172 patients with PGDU who underwent surgery for the period 2014-2016. The research was performed at the bases of the Department of Faculty-Based Surgery No. 1 of the Medical Faculty of the Pirogov Russian National Research Medical University. Further analysis enrolled 138 patients in accordance with inclusion and exclusion criteria (laparoscopic intervention - 116 patients, open surgery - 22). Propensity score matching (pseudorandomization) was applied after comparative analysis of patients' characteristics and treatment outcomes in order to ensure maximum comparability of both groups.

RESULTS

Length of hospital-stay (7.1 vs. 9.8 days), incidence of extra-abdominal complications (6.3%. vs. 41.2%) and adverse events Clavien-Dindo grade II (6.3% vs. 35.3%) were significantly lower after minimally invasive surgery (p<0.05).

CONCLUSION

Analysis of comparable groups of patients with PGDU complicated by peritonitis revealed that laparoscopic surgery is accompanied by significantly lower incidence of extra-abdominal postoperative complications and shorter hospital-stay compared with open surgery. Mortality and incidence of intra-abdominal postoperative complications were similar in both groups.

The impact of age and comorbidity on the postoperative outcomes after emergency surgical management of complicated intra-abdominal infections

Age-adjusted Charlson Comorbidity Index (a-CCI) score has been used to weight comorbid conditions in predicting adverse outcomes. A retrospective cohort study on adult patients diagnosed with complicated intra-abdominal infections (cIAI) requiring emergency surgery was conducted in order to elucidate the role of age and comorbidity in this scenario. Two main outcomes were evaluated: 90-day severe postoperative complications (grade ≥ 3 of Dindo-Clavien Classification), and 90-day all-cause mortality. 358 patients were analyzed. a-CCI score for each patient was calculated and then divided in two comorbid categories whether they were ≤ or > to percentile 75 ( = 4): Grade-A (0-4) and Grade-B ( ≥ 5). Univariate and multivariate regression analyses were performed, and the predictive validity of the models was evaluated by the area under the receiver operating characteristics (AUROC) curve. Independent predictors of 90-day severe postoperative complications were Charlson Grade-B (Odds Ratio [OR] = 3.49, 95% confidence interval [95%CI]: 1.86-6.52; p < 0.0001), healthcare-related infections (OR = 7.84, 95%CI: 3.99-15.39; p < 0.0001), diffuse peritonitis (OR = 2.64, 95%CI: 1.45-4.80; p < 0.01), and delay of surgery > 24 hours (OR = 2.28, 95%CI: 1.18-4.68; p < 0.02). The AUROC was 0.815 (95%CI: 0.758-0.872). Independent predictors of 90-day mortality were Charlson Grade-B (OR = 8.30, 95%CI: 3.58-19.21; p < 0.0001), healthcare-related infections (OR = 6.38, 95%CI: 2.72-14.95; p < 0.0001), sepsis status (OR = 3.98, 95%CI: 1.04-15.21; p < 0.04) and diffuse peritonitis (OR = 3.06, 95%CI: 1.29-7.27; p < 0.01). The AUROC for mortality was 0.887 (95%CI: 0.83-0.93). Post-hoc sensitivity analyses confirmed that the degree of comorbidity, estimated by using an age-adjusted score, has a critical impact on the postoperative course following emergency surgery for cIAI. Early assessment and management of patient's comorbidity is mandatory at emergency setting.

Descriptive and correlational study of peritonitis in the surgical department of the State University hospital of Haïti (HUEH): A cross sectional study

Background:

Generalized secondary peritonitis is one of the most common emergencies encountered in the surgical department. It is a major surgical condition with mortality of up to 20% and classified as the third most common cause of surgical abdomen after appendicitis and intestinal obstruction. In Haiti, few studies on surgical pathology are available.

Materials and methods:

This is a correlational descriptive study carried out in the State University Hospital of Haiti (HUEH) surgery department over 6 years (2013–2018) with a sample of 91 patients.

Results:

The mean patient age was 27.29 years (±13.28). The 3 most common diagnoses were appendicular peritonitis (48.35%), typhoid peritonitis (18.68%), and gastric perforation peritonitis (10.99%). Delays were more substantial for women than men (5.18 vs. 2.89 days, for the pre-operative period; 11.79 vs. 7.68 days, for the post-operative period, and 16.97 vs. 10.47 days, for duration of hospital stay). The mean MPI score is 23.3, and was an association between MPI severity score with age (r = 0.37; p = 0.002), pre-op duration (r = 0.28, p = 0.024) and duration of hospital stay (r = 0.24; p = 0.046). Multiple linear regression revealed that only creatininemia, pre-op duration, and age influence the severity score. Thus, we observed a strong correlation between these 3 variables and the MPI score (r = 0.69), with 48.7% of the score variation being influenced by these 3 variables (p = 0.014).

Conclusion:

Peritonitis is a disease mainly of young adult males, and the predominant etiology is appendicular peritonitis. Management is urgent, but delays in care are important and are correlated to the severity of the disease, potentially affecting outcomes for patients who need treatment the most.

Highlights:

Clinical implications of multidrug-resistant microorganisms and fungi isolated from patients with intra-abdominal infections in the Republic of Korea: a multicenter study

The purpose of this study was to evaluate the clinical significance of fungi and multidrug-resistant organisms (MDROs) isolated from patients with intra-abdominal infections (IAIs). This multicenter study included consecutive patients admitted for microbiologically proven IAIs at 6 university-affiliated hospitals in South Korea between 2016 and 2018. A total of 1571 patients were enrolled. Multivariable logistic regression analysis revealed that the isolation of MDROs, isolation of Candida spp., underlying renal diseases, Charlson comorbidity score ≥ 3, septic shock, failure to receive a required surgery or invasive intervention, secondary bacteremia due to IAIs, and lower body mass index were found to be independent predictors for 28-day mortality. However, the isolation of Enterococcus spp. was not identified as a significant risk factor. MDROs and Candida spp. were found in 42 (2.7%) and 395 (25.1%), patients respectively. The isolation of MDROs or Candida spp. was a surrogate marker of 28-day mortality.

Intra-abdominal infections: the role of different classifications on the selection of the best antibiotic treatment

Background

Intra-abdominal infections (IAIs) represent a most frequent gastrointestinal emergency and serious cause of morbimortality. A full classification, including all facets of IAIs, does not exist. Two classifications are used to subdivide IAIs: uncomplicated or complicated, considering infection extent; and community-acquired, healthcare-associated or hospital-acquired, regarding the place of acquisition. Adequacy of initial empirical antibiotic therapy prescribed is an essential need. Inadequate antibiotic therapy is associated with treatment failure and increased mortality. This study was designed to determine accuracy of different classifications of IAIs to identify infections by pathogens sensitive to current treatment guidelines helping the selection of the best antibiotic therapy.

Methods

A retrospective cohort study including all adult patients discharged from hospital with a diagnosis of IAI between 1st of January and 31st of October, 2016. All variables potentially associated with pre-defined outcomes: infection by a pathogen sensitive to non-pseudomonal cephalosporin or ciprofloxacin plus metronidazole (ATB 1, primary outcome), sensitive to piperacillin-tazobactam (ATB 2) and hospital mortality (secondary outcomes) were studied through logistic regression. Accuracy of the models was assessed by area under receiver operating characteristics (AUROC) curve and calibration was tested using the Hosmer-Lemeshow goodness-of-fit test.

Results

Of 1804 patients screened 154 met inclusion criteria. Sensitivity to ATB 1 was independently associated with male gender (adjusted OR = 2.612) and previous invasive procedures in the last year (adjusted OR = 0.424) (AUROC curve = 0,65). Sensitivity to ATB 2 was independently associated with liver disease (adjusted OR = 3.580) and post-operative infections (adjusted OR = 2.944) (AUROC curve = 0.604). Hospital mortality was independently associated with age ≥ 70 (adjusted OR = 4.677), solid tumour (adjusted OR = 3.127) and sensitivity to non-pseudomonal cephalosporin or ciprofloxacin plus metronidazole (adjusted OR = 0.368).

The accuracy of pre-existing classifications to identify infection by a pathogen sensitive to ATB 1 was 0.59 considering place of acquisition, 0.61 infection extent and 0.57 local of infection, for ATB 2 it was 0.66, 0.50 and 0.57, respectively.

Conclusion

None of existing classifications had a good discriminating power to identify IAIs caused by pathogens sensitive to current antibiotic treatment recommendations. A new classification, including patients’ individual characteristics like those included in the current model, might have a higher potential to distinguish IAIs by resistant pathogens allowing a better choice of empiric antibiotic therapy.

Carbapenems vs tigecycline for the treatment of complicated intra-abdominal infections: A Bayesian network meta-analysis of randomized clinical trials

BACKGROUND

Complicated intra-abdominal infections (cIAIs) are common in clinical practice, caused by a mixture of aerobic and anaerobic bacteria, increase the risk of mortality. Carbapenems and tigecycline (TGC) are recommended for antimicrobial therapies for cIAIs.

OBJECTIVE

To compare the effectiveness and safety of different carbapenems vs TGC for the treatment of cIAIs.

METHODS

PubMed, Embase, Medline (via Ovid SP) and Cochrane library databases were systematically searched. We included randomized controlled trials (RCTs) comparing different carbapenems vs TGC for the treatment of cIAIs. The pooled odds ratio (OR) with 95% credible interval (CrI) was calculated by Markov chain Monte Carlo methods. We estimated summary ORs using pairwise and network meta-analysis with random effects.

RESULTS

Fifteen studies involving 6745 participants were included in the analysis. Five different carbapenems and TGC were ultimately evaluated in this study. Although, the efficacy of carbapenems and TGC by ORs with corresponding 95% CrIs had not yet reached statistical differences, the cumulative rank probability indicated that clinical treatment success from best to worst was doripenem (DOPM), meropenem (MEPM), imipenem/cilastatin (IC), biapenem (BAPM), TGC and imipenem/cilastatin/relebactam (ICRB); microbiological treatment success from best to worst was DOPM, MEPM, IC, BAPM, ICRB and TGC. As for the risk of adverse events (AEs), TGC showed higher risk of AEs compared with IC (OR = 1.53, 95% CrI = 1.02-2.41), the remain antibiotic agents from lower to higher was MEPM, IC, BAPM, DOPM, ICRB and TGC. The risk of mortality from lower to higher was BAPM, DOPM, MEPM, IC, TGC and ICRB.

CONCLUSION

No differences in clinical and microbiological outcomes were observed between different carbapenems and TGC. Balancing the evidence for drug efficacy and side effects, DOPM appears to be the best available treatment for cIAIs. Therefore, it is reasonable to consider that DOPM is one of the best carbapenem monotherapy for cIAIs. MEPM and IC was also associated with higher rates of clinical and microbiological treatment success following DOPM. Empiric antimicrobial treatment of patients with cIAIs should be selected in light of the local bacterial epidemiology and patterns of resistance.

Carbapenems vs β-Lactam Monotherapy or Combination Therapy for the Treatment of Complicated Intra-abdominal Infections: Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

Complicated intra-abdominal infections (cIAIs) result in significant morbidity, mortality, and cost. Carbapenem-resistant sepsis has increased dramatically in the last decade, resulting in infections that are difficult to treat and associated with high mortality rates. To prevent further antibacterial resistance, it is necessary to use carbapenem selectively. The objective of this study was to compare the effectiveness and safety of carbapenems vs alternative β-lactam monotherapy or combination therapy for the treatment of cIAIs.

Methods

The PubMed, Embase, Medline (via Ovid SP), and Cochrane library databases were systematically searched. We included randomized controlled trials (RCTs) comparing carbapenems vs alternative β-lactam monotherapy or combination therapy for the treatment of cIAIs.

Results

Twenty-two studies involving 7720 participants were included in the analysis. There were no differences in clinical treatment success (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.71–1.05; I² = 35%), microbiological treatment success (OR, 0.88; 95% CI, 0.71–1.09; I² = 25%), adverse events (OR, 0.98; 95% CI, 0.87–1.09; I² = 17%), or mortality (OR, 0.96; 95% CI, 0.68–1.35; I² = 7%). Patients

treated with imipenem were more likely to experience clinical or microbiological failure than those treated with alternative β-lactam monotherapy or combination therapy.

Conclusions

No differences in clinical outcomes were observed between carbapenems and noncarbapenem β-lactams in cIAIs. Patients treated with imipenem were more likely to experience clinical or microbiological failure than those treated with alternative β-lactam monotherapy or combination therapy.

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

BACKGROUND

The benefit of taking intra-abdominal cultures during source control procedures in patients with complicated intra-abdominal infection (CIAI) is unknown. The aim of this study was to evaluate whether intra-abdominal cultures reduce the mortality rate of CIAI.

METHODS

The Japanese Diagnosis Procedure Combination database was used to identify adult patients with CIAI who had undergone source control procedures on the first day of admission to hospital between April 2014 and March 2016. In-hospital mortality was compared between patients who did and those who did not have intra-abdominal cultures taken. A generalized linear mixed-effect logistic regression model and a random intercept per hospital were used to adjust for baseline confounders and institutional differences. Subgroup analyses were also performed according to disease cause, site of onset and severity of CIAI.

RESULTS

Intra-abdominal cultures were taken from 16 303 of 41 495 included patients. Multivariable logistic regression analysis showed that patients with intra-abdominal cultures had a significantly lower mortality than those without (odds ratio 0·85, 95 per cent c.i. 0·77 to 0·95). Subgroup analyses revealed statistically significant differences in mortality between patients with and without cultures among those with lower intestinal perforation, biliary tract infection/perforation, healthcare-associated CIAI and high-risk community-acquired CIAI.

CONCLUSIONS

Intra-abdominal cultures obtained during source control procedures may reduce in-hospital mortality, especially in patients with lower intestinal perforation, biliary tract infection/perforation, or healthcare-associated or high-risk community-acquired CIAI.