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Rebelo A, Schlicht L, Kleeff J, Michalski CW, Heckler M. Carbapenem Antibiotics Versus Other Antibiotics for Complicated Intra-abdominal Infections: a Systematic Review and Patient-Level Meta-analysis of Randomized Controlled Trials (PROSPERO CRD42018108854). J Gastrointest Surg 2023; 27:1208-1215. [PMID: 36949237 PMCID: PMC10267009 DOI: 10.1007/s11605-023-05651-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/18/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND The treatment of complicated intra-abdominal infections remains a challenge. Both optimal medical and surgical therapy (i.e., source control) are needed to achieve low mortality and morbidity. The objective of this systematic review and meta-analysis is to determine the impact of carbapenem antibiotic therapy compared to other antibiotics in complicated intra-abdominal infections (secondary peritonitis) with an emphasis on mortality and postoperative complications. METHODS A systematic literature search from PubMed/Medline and Web of Science databases was carried out. The last search was conducted in August 2022. PRISMA guidelines were followed. Pre-defined outcomes were mortality, treatment success, treatment failure, and adverse events. RESULTS Ten randomized controlled trials, published from 1983 to 2013 with a total of 2377 patients (1255 patients in the carbapenem antibiotics group and 1122 in the control group), were identified. A meta-analysis comparing patients undergoing carbapenem antibiotic therapy and patients receiving other antibiotics was performed. No significant difference regarding mortality (OR 1.19, 95% CI [0.79; 1.82], p = 0.40), treatment success (OR 1.17, 95% CI [0.72; 1.91], p = 0.53), and treatment failure (OR 0.84, 95% CI [0.48; 1.45], p = 0.52) was observed. Carbapenem therapy was associated with fewer adverse events compared to therapy with other antibiotics (OR 0.79, 95% CI [0.65; 0.97], p = 0.022). CONCLUSION There is currently no evidence that carbapenem antibiotics are superior in terms of mortality, and success or failure for the treatment of complicated intra-abdominal infections (secondary peritonitis). The rate of adverse events is lower under carbapenem therapy compared to control antibiotics. TRIAL REGISTRATION PROSPERO 2018 CRD42018108854.
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Affiliation(s)
- Artur Rebelo
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Halle, Germany
| | - Laura Schlicht
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Halle, Germany
| | - Jörg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Halle, Germany
| | - Christoph W Michalski
- Department of General- and Visceral Surgery, University Hospital Ulm, Ulm University, Ulm, Germany
- Department of General-, Visceral- and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Max Heckler
- Department of General-, Visceral- and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
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Wu X, Wu J, Wang P, Fang X, Yu Y, Tang J, Xiao Y, Wang M, Li S, Zhang Y, Hu B, Ma T, Li Q, Wang Z, Wu A, Liu C, Dai M, Ma X, Yi H, Kang Y, Wang D, Han G, Zhang P, Wang J, Yuan Y, Wang D, Wang J, Zhou Z, Ren Z, Liu Y, Guan X, Ren J. 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. Clin Infect Dis 2021; 71:S337-S362. [PMID: 33367581 DOI: 10.1093/cid/ciaa1513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jie Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,BenQ Medical Center, Nanjing Medical University, Nanjing, China
| | - Peige Wang
- Department of Emergency Medicine, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xueling Fang
- Department of Critical Care Medicine, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianguo Tang
- Department of Emergency Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Yonghong Xiao
- Department of Infectious Diseases, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Shikuan Li
- Department of Emergency Medicine, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Bijie Hu
- Department of Infectious Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Ma
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Qiang Li
- Department of General Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhiming Wang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Anhua Wu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Chang Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Menghua Dai
- Department of Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Huimin Yi
- Department of Critical Care Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Daorong Wang
- Department of General Surgery, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Gang Han
- Department of Gastroenterology, Second Hospital of Jilin University, Changchun, China
| | - Ping Zhang
- Department of General Surgery, First Hospital of Jilin University, Changchun, China
| | - Jianzhong Wang
- Department of Gastroenterology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Yufeng Yuan
- Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dong Wang
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China
| | - Jian Wang
- Department of Biliary and Pancreatic Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zheng Zhou
- Department of General Surgery, First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Zeqiang Ren
- Department of General Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yuxiu Liu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiangdong Guan
- Department of Critical Care Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Li Y, Chen L, Jiang J, Li X, Huang T, Liang X. 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. Open Forum Infect Dis 2019; 6:ofz394. [PMID: 31660356 PMCID: PMC6786516 DOI: 10.1093/ofid/ofz394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 09/05/2019] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Yan Li
- Department of Pharmacy, The People's Hospital of Hechi, Hechi, China
| | - Lingyuan Chen
- Department of Pharmacy, The People's Hospital of Hechi, Hechi, China
| | - Junsong Jiang
- Department of Reproductive Medicine, The People's Hospital of Hechi, Hechi, China
| | - Xianshu Li
- Department of Pharmacy, The People's Hospital of Hechi, Hechi, China
| | - Tianguo Huang
- Department of Pharmacy, The People's Hospital of Hechi, Hechi, China
| | - Xueyan Liang
- Department of Pharmacy, The People's Hospital of Hechi, Hechi, China
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Mikamo H, Yuasa A, Wada K, Crawford B, Sugimoto N. Optimal Treatment for Complicated Intra-abdominal Infections in the Era of Antibiotic Resistance: A Systematic Review and Meta-Analysis of the Efficacy and Safety of Combined Therapy With Metronidazole. Open Forum Infect Dis 2016; 3:ofw143. [PMID: 27704002 PMCID: PMC5047423 DOI: 10.1093/ofid/ofw143] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 07/01/2016] [Indexed: 01/29/2023] Open
Abstract
Background. Carbapenem-resistant Enterobacteriaceae 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. A combination of metronidazole with an antimicrobial agent active against aerobes is an alternative effective treatment for patients with complicated intra-abdominal infections (cIAIs). This study aimed to compare efficacy and safety of metronidazole combination therapies and carbapenem and to provide clinical evidence regarding the optimal treatment of cIAI. Methods. A systematic review and a meta-analysis of randomized clinical trials in the treatment of cIAI were conducted. The systematic review with PubMed, Embase, and the Cochrane Database of Systematic Reviews followed the Cochrane Handbook's recommended methodology, and the meta-analysis used a Mantel-Haenszel random-effects model with RevMan, version 5.3. Primary endpoints were clinical success and bacteriological eradication, and secondary endpoints were all-cause mortality and drug-related adverse events. Results. Eight studies comparing metronidazole combination therapies and carbapenem were included in the meta-analysis. No difference was found between combined therapy with metronidazole and carbapenem regarding clinical success (odds ratio [OR] = 1.31; 95% confidence interval [CI], .75-2.31), bacteriological eradication (OR = 1.27; 95% CI, .84-1.91), all-cause mortality (OR = 0.61; 95% CI, .37-1.00), or drug-related adverse events (OR = 0.58; 95% CI, .18-1.88). Sensitivity analyses found similar results. Conclusions. Combined therapy with metronidazole is as effective and safe as carbapenem in treatment of cIAI. Therefore, combined therapy with metronidazole offers an effective alternative to carbapenem with low risk of drug resistance.
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Affiliation(s)
- Hiroshige Mikamo
- Department of Clinical Infectious Diseases , Aichi Medical University Graduate School of Medicine , Nagakute
| | - Akira Yuasa
- Medical Affairs Department , Pfizer Japan Inc
| | - Keiko Wada
- Real-World Evidence Solutions and Health Economics and Outcomes Research, IMS Japan K.K. , Tokyo
| | - Bruce Crawford
- Real-World Evidence Solutions and Health Economics and Outcomes Research, IMS Japan K.K. , Tokyo
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Combination therapy for treatment of infections with gram-negative bacteria. Clin Microbiol Rev 2012; 25:450-70. [PMID: 22763634 DOI: 10.1128/cmr.05041-11] [Citation(s) in RCA: 539] [Impact Index Per Article: 44.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Combination antibiotic therapy for invasive infections with Gram-negative bacteria is employed in many health care facilities, especially for certain subgroups of patients, including those with neutropenia, those with infections caused by Pseudomonas aeruginosa, those with ventilator-associated pneumonia, and the severely ill. An argument can be made for empiric combination therapy, as we are witnessing a rise in infections caused by multidrug-resistant Gram-negative organisms. The wisdom of continued combination therapy after an organism is isolated and antimicrobial susceptibility data are known, however, is more controversial. The available evidence suggests that the greatest benefit of combination antibiotic therapy stems from the increased likelihood of choosing an effective agent during empiric therapy, rather than exploitation of in vitro synergy or the prevention of resistance during definitive treatment. In this review, we summarize the available data comparing monotherapy versus combination antimicrobial therapy for the treatment of infections with Gram-negative bacteria.
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Abad CL, Kumar A, Safdar N. Antimicrobial therapy of sepsis and septic shock--when are two drugs better than one? Crit Care Clin 2011; 27:e1-27. [PMID: 21440195 DOI: 10.1016/j.ccc.2010.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In clinical practice, physicians frequently use combination therapy despite the conflicting evidence for its effectiveness. The results of recent studies have contributed to our understanding of this important issue. In this article, we examine the evidence for, or against, the use of combination drug therapy compared with monotherapy in the management of serious infections, sepsis, and septic shock.
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Affiliation(s)
- Cybéle L Abad
- Department of Internal Medicine, Section of Infectious Diseases, University of Wisconsin Hospital and Clinics, 1685 Highland Avenue, Madison, WI 53705, USA
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Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJC, Baron EJ, O'Neill PJ, Chow AW, Dellinger EP, Eachempati SR, Gorbach S, Hilfiker M, May AK, Nathens AB, Sawyer RG, Bartlett JG. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Surg Infect (Larchmt) 2010; 11:79-109. [PMID: 20163262 DOI: 10.1089/sur.2009.9930] [Citation(s) in RCA: 310] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.
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Affiliation(s)
- Joseph S Solomkin
- Department of Surgery, the University of Cincinnati College of Medicine, 231 Albert B. Sabin Way, Cincinnati, OH 45267-0558, USA.
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8
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Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, O'Neill PJ, Chow AW, Dellinger EP, Eachempati SR, Gorbach S, Hilfiker M, May AK, Nathens AB, Sawyer RG, Bartlett JG. Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010; 50:133-64. [PMID: 20034345 DOI: 10.1086/649554] [Citation(s) in RCA: 974] [Impact Index Per Article: 69.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Abstract
Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003–2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.
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Affiliation(s)
- Joseph S. Solomkin
- Department of Surgery, the University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John E. Mazuski
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | | | - Keith A Rodvold
- Department of Pharmacy Practice, Chicago
- Department of Medicine, University of Illinois at Chicago, Chicago
| | - Ellie J.C. Goldstein
- R. M. Alden Research Laboratory, David Geffen School of Medicine at UCLA, Los Angeles
| | - Ellen J. Baron
- Department of Pathology, Stanford University School of Medicine, Palo Alto, California
| | - Patrick J. O'Neill
- Department of Surgery, The Trauma Center at Maricopa Medical Center, Phoenix, Arizona
| | - Anthony W. Chow
- Department of Medicine, University of British Columbia, Vancouver, British Columbia
| | | | | | - Sherwood Gorbach
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Mary Hilfiker
- Department of Surgery, Rady Children's Hospital of San Diego, San Diego
| | - Addison K. May
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - John G. Bartlett
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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9
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Chow AW, Evans GA, Nathens AB, Ball CG, Hansen G, Harding GKM, Kirkpatrick AW, Weiss K, Zhanel GG. Canadian practice guidelines for surgical intra-abdominal infections. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2010; 21:11-37. [PMID: 21358883 PMCID: PMC2852280 DOI: 10.1155/2010/580340] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Anthony W Chow
- Division of Infectious Disease, Department of Medicine, University of British Columbia and Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia
| | - Gerald A Evans
- Division of Infectious Diseases, Department of Medicine, Queen’s University, Kingston
| | - Avery B Nathens
- Department of Surgery, University of Toronto, Toronto, Ontario
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta
| | - Glen Hansen
- Departments of Pathology and Laboratory Medicine, University of Minnesota and Hennepin County Medical Center, Minnesota, USA
| | - Godfrey KM Harding
- Department of Medical Microbiology and Medicine, University of Manitoba, Winnipeg, Manitoba
| | | | - Karl Weiss
- Department of Infectious Diseases and Microbiology, Hôspital Maisonneuve-Rosemont, University of Montreal, Montreal, Quebec
| | - George G Zhanel
- Department of Medical Microbiology and Medicine, University of Manitoba, Winnipeg, Manitoba
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11
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12
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Kioumis IP, Kuti JL, Nicolau DP. Intra-abdominal infections: considerations for the use of the carbapenems. Expert Opin Pharmacother 2007; 8:167-82. [PMID: 17257087 DOI: 10.1517/14656566.8.2.167] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Intra-abdominal infection remains a common and frequently severe medical condition, carrying with it significant morbidity and mortality. These infections are almost always polymicrobial in nature as they are caused by mixed aerobic/anaerobic intestinal flora. Despite substantial improvements in both the medical and surgical management of these infections over the last several decades, there remains an opportunity to further enhance the utilization of adjunctive antibiotic therapy. As a result of the epidemiology and the current resistance profile of the infecting pathogens, the carbapenems represent a class of antibiotics that are considered appropriate for the treatment of severe intra-abdominal infections. This review will discuss the classification and microbiology of these infections and emerging resistance in the pathogens of interest. The review also and focuses on the role of the carbapenems in the management of the constellation of diseases known as intra-abdominal infection.
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Affiliation(s)
- Ioannis P Kioumis
- Center for Anti-infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
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13
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Mazuski JE, Sawyer RG, Nathens AB, DiPiro JT, Schein M, Kudsk KA, Yowler C. The Surgical Infection Society guidelines on antimicrobial therapy for intra-abdominal infections: an executive summary. Surg Infect (Larchmt) 2006; 3:161-73. [PMID: 12542922 DOI: 10.1089/109629602761624171] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
The Surgical Infection Society last published guidelines on antimicrobial therapy for intra-abdominal infections in 1992 (Bohnen JMA, et al., Arch Surg 1992;127:83-89). Since then, an appreciable body of literature has been published on this subject. Therefore, the Therapeutics Agents Committee of the Society undertook an effort to update the previous guidelines, primarily using data published over the past decade. An additional goal of the Committee was to characterize its recommendations according to contemporary principles of evidence-based medicine. To develop these guidelines, the Committee carried out a systematic search for all English language articles published between 1990 and 2000 related to antimicrobial therapy for intra-abdominal infections. This literature was reviewed individually and collectively by the Committee, and categorized according to the type of study and its quality. Additional articles published prior to 1990 were also utilized when necessary. By a process of iterative consensus, the Committee developed provisional guidelines for antimicrobial therapy for intra-abdominal infections based on this evidence. Following extensive review by members of the Society, these guidelines were approved for publication in final form by the Council of the Surgical Infection Society. This executive summary delineates the Society's current recommendations for antimicrobial therapy of patients with intra-abdominal infections. Topics discussed include the selection of patients needing therapeutic antimicrobials, duration of antimicrobial therapy, acceptable antimicrobial regimens, and identification and treatment of higher-risk patients. Guidelines for patient selection and specific antimicrobial regimens were based on relatively good evidence, but those regarding optimal duration of therapy and treatment of higher-risk patients relied mostly on expert opinion, since there was a paucity of high-quality studies on those issues. Relevant areas for future investigation include the safety, convenience, and cost-effectiveness of available antimicrobial regimens for lower-risk patients, and better means for identifying and treating higher-risk patients with intra-abdominal infections.
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Affiliation(s)
- John E Mazuski
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, MO 63110-1093, and Bronx Lebanon Hospital Center, Bronx, NY, USA.
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14
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Mazuski JE, Sawyer RG, Nathens AB, DiPiro JT, Schein M, Kudsk KA, Yowler C. The Surgical Infection Society guidelines on antimicrobial therapy for intra-abdominal infections: evidence for the recommendations. Surg Infect (Larchmt) 2006; 3:175-233. [PMID: 12542923 DOI: 10.1089/109629602761624180] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Revised guidelines for the use of antimicrobial therapy in patients with intra-abdominal infections were recently developed by the Therapeutic Agents Committee of the Surgical Infection Society (Mazuski et al., Surg Infect 2002;3:161-173). These were based, insofar as possible, on evidence published over the past decade. The objective of this document is to describe the process by which the Committee identified and reviewed the published literature utilized to develop the recommendations and to summarize the results of those reviews. English-language articles published between 1990 and 2000 related to antimicrobial therapy for intra-abdominal infections were identified by a systematic MEDLINE search and an examination of references included in recent review articles. If current literature with regard to a specific issue was lacking, relevant articles published prior to 1990 were identified. All prospective randomized controlled trials, as well as other articles selected by the Committee, were evaluated individually and collectively. Data with regard to patient numbers, types of infections, and results of interventions were abstracted. Studies were categorized according to their design, and all included trials were graded according to quality. On the basis of this evidence, the Committee formulated recommendations for antimicrobial therapy for intra-abdominal infections and graded those recommendations. After receiving comments from invited reviewers and the general membership of the Society, the guidelines were finalized and submitted to the Council of the Surgical Infection Society for approval. The final recommendations related to the selection of patients needing therapeutic antimicrobials, acceptable antimicrobial regimens, duration of antimicrobial use, and the identification and treatment of higher-risk patients. Although numerous publications pertaining to these topics were identified, but nearly all of the prospective randomized controlled trials represented comparisons of different antimicrobial regimens for the treatment of intra-abdominal infections. A few prospective trials evaluated the need for therapeutic antimicrobial therapy in patients with peritoneal contamination following abdominal trauma. The quality of these prospective trials was highly variable. Many did not limit enrollment to patients with complicated intra-abdominal infections, lacked blinding of treatment assignment, did not provide a complete description of the criteria used to determine therapeutic success or failure, failed to identify the reasons why patients were excluded from analysis, or did not include an intention-to-treat analysis. For many issues, no prospective randomized controlled trials were encountered, and guidelines had to be formulated using evidence from studies with historical controls or uncontrolled data, or on the basis of expert opinion
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Affiliation(s)
- John E Mazuski
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, MO 63110-1093, and Bronx Lebanon Hospital Center, Bronx, NY, USA.
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Wong PF, Gilliam AD, Kumar S, Shenfine J, O'Dair GN, Leaper DJ. Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults. Cochrane Database Syst Rev 2005; 2005:CD004539. [PMID: 15846719 PMCID: PMC11297476 DOI: 10.1002/14651858.cd004539.pub2] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Secondary peritonitis is associated with a high mortality rate and if not treated successfully leads to development of abscesses, severe sepsis and multi-organ failure. Source control and adjunctive antibiotics are the mainstay of treatment. However, no conclusive evidence suggest that one antibiotic regimen is better than any other but at the same time have a lower toxicity. OBJECTIVES To ascertain the efficacy and adverse effects of different antibiotic regimens in treating intra-abdominal infections in adults. Outcomes were divided into primary (clinical success and effectiveness in reducing mortality) and secondary (microbiological success, preventing wound infection, intra-abdominal abscess, clinical sepsis, remote infection, superinfection, adverse reactions, duration of treatment required, effectiveness in reducing hospitalised stay, and time to defervescence). SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 4, 2004), MEDLINE (from 1966 to November 2004), EMBASE (from 1980 to November 2004) and Cochrane Colorectal Cancer Group specialised register SR-COLOCA. Bibliographies of identified studies were screened for further relevant trials. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing different antibiotic regimens in the treatment of secondary peritonitis in adults were selected. Trials reporting gynaecological or traumatic peritonitis were excluded from this review. Ambiguity regarding suitability of trials were discussed among the review team. DATA COLLECTION AND ANALYSIS Six reviewers independently assessed trial quality and extracted data. Data collection was standardised using data collection form to ensure uniformity among reviewers. Statistical analyses were performed using the random effects model and the results expressed as odds ratio for dichotomous outcomes, or weight mean difference for continuous data with 95% confidence intervals. MAIN RESULTS Fourty studies with 5094 patients met the inclusion criteria. Sixteen different comparative antibiotic regimens were reported. All antibiotics showed equivocal comparability in terms of clinical success. Mortality did not differ between the regimens. Despite the potential high toxicity profile of regimens using aminoglycosides, this was not demonstrated in this review. The reason for this could be the inherent bias within clinical trials in the form of patient selection and stringency in monitoring drug levels. AUTHORS' CONCLUSIONS No specific recommendations can be made for the first line treatment of secondary peritonitis in adults with antibiotics, as all regimens showed equivocal efficacy. Other factors such as local guidelines and preferences, ease of administration, costs and availability must therefore be taken into consideration in deciding the antibiotic regimen of choice. Future trials should attempt to stratify patients and perform intention-to-treat analysis to allow better external validity.
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Affiliation(s)
- P F Wong
- Professorial Unit of Surgery, University Hospital of North Tees, Hardwick, Stockton on Tees, UK, TS19 8PE.
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Nooteboom A, van der Linden CJ, Hendriks T. Whole blood-mediated endothelial permeability and adhesion molecule expression: a model study into the effects of bacteria and antibiotics. J Antimicrob Chemother 2005; 55:150-6. [PMID: 15650003 DOI: 10.1093/jac/dkh526] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
AIM To investigate whether the inflammatory response of cultured endothelial cells, as induced by conditioned plasma, depends on the bacterial species or type of antibiotic used for incubation with whole blood. MATERIALS AND METHODS Blood from healthy volunteers was stimulated ex vivo with different microorganisms, and with bacteria killed with different antibiotics. The resultant plasmas were incubated on monolayers of cultured human endothelial cells, followed by measurement of their permeability to albumin and expression of E-selectin and intercellular adhesion molecule-1. RESULTS Incubation of Escherichia coli in blood yielded plasmas that induced a marked increase in endothelial permeability and E-selectin expression. The response to Bacteroides fragilis or Enterococcus faecalis was generally weaker. Similar effects were observed after incubation of whole blood with lipopolysaccharide (LPS). Much of the permeability and adhesion molecule response to E. coli remained after removal of intact microorganisms from the culture. Whereas antibiotic treatment of E. coli with imipenem or cefuroxime resulted in a divergent production of tumour necrosis factor-alpha (TNF-alpha) in blood, no significant differences between these treatments were observed with respect to the plasma-induced endothelial response. CONCLUSION Bacteria differ in their capacity to generate a whole blood-mediated increase of endothelial permeability and adhesion molecule expression; this response depends, at least in part, on the presence of soluble bacterial components, such as LPS. Whereas treatment with various antibiotics may generate varying amounts of TNF-alpha, these differences are not translated into differences in endothelial permeability or adhesion molecule expression.
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Affiliation(s)
- Arjan Nooteboom
- Department of Surgery, University Medical Centre Nijmegen, PO box 9101, 6500 HB Nijmegen.
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Solomkin JS, Mazuski JE, Baron EJ, Sawyer RG, Nathens AB, DiPiro JT, Buchman T, Dellinger EP, Jernigan J, Gorbach S, Chow AW, Bartlett J. Guidelines for the Selection of Anti-infective Agents for Complicated Intra-abdominal Infections. Clin Infect Dis 2003; 37:997-1005. [PMID: 14523762 DOI: 10.1086/378702] [Citation(s) in RCA: 379] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Accepted: 06/30/2003] [Indexed: 02/02/2023] Open
Affiliation(s)
- Joseph S Solomkin
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0558, USA.
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Dietrich ES, Schubert B, Ebner W, Daschner F. Cost efficacy of tazobactam/piperacillin versus imipenem/cilastatin in the treatment of intra-abdominal infection. PHARMACOECONOMICS 2001; 19:79-94. [PMID: 11252548 DOI: 10.2165/00019053-200119010-00006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To compare the cost, efficacy and cost efficacy of tazobactam/piperacillin and imipenem/cilastatin in the treatment of intra-abdominal infection. DESIGN The analysis was retrospective and based on a decision tree. Effectiveness data were obtained from 19 published clinical trials. Direct costs were quantified per patient from the time the decision was made to administer the antibacterial to the end of the first course of treatment or the end of a subsequent course of treatment, if required. The primary end-point was the cost per successfully treated patient. The cost per life saved was also analysed. Various follow-up times were taken into account. PERSPECTIVE German National Health Insurance funds. STUDY POPULATION 1744 patients with intra-abdominal infection. INTERVENTIONS Tazobactam/piperacillin (total daily dosage of 13.5 g/day) and imipenem/cilastatin (total daily dosage of 1.5 to 4 g/day). The mean duration of treatment varied from 5.5 to 8.2 days for tazobactam/piperacillin and 5 to 9.4 days for imipenem/cilastatin. MAIN OUTCOME MEASURE AND RESULTS Compared with imipenem/cilastatin, treatment with tazobactam/piperacillin was more effective and the overall treatment costs were lower. In the base-case analysis, the cost-efficacy ratio (cost per successfully treated patient) was 7881 German deutschmarks (DM) for tazobactam/piperacillin and DM11,390 for imipenem/cilastatin. The incremental cost-efficacy ratio (per life saved) varied between -DM72,567 and -DM350,738 for tazobactam/piperacillin. Sensitivity analyses revealed that the results were robust against various assumptions on cost parameters, clinical outcomes and length of treatment. All costs reflect 1998 values; $US1 = DM1.85. CONCLUSIONS This study suggests that compared with imipenem/cilastatin, tazobactam/piperacillin is more cost efficacious in the treatment of intra-abdominal infections and that it offers a cost advantage through fewer relapses and lower daily therapeutic costs.
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Affiliation(s)
- E S Dietrich
- Institute of Environmental Medicine and Hospital Epidemiology, University Hospital, Freiburg, Germany
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Cinat ME, Wilson SE. New advances in the use of antimicrobial agents in surgery: intra-abdominal infections. J Chemother 1999; 11:453-63. [PMID: 10678787 DOI: 10.1179/joc.1999.11.6.453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Advances in both technical methods and antimicrobial therapy have significantly reduced morbidity and mortality for secondary (enterogenous) or community-acquired intra-abdominal infections. Presumptive antimicrobial therapy for most community-acquired intra-abdominal infection can be safely initiated with a single broad-spectrum antimicrobial effective against the expected Enterobacteriaceae and anaerobic flora. Beta-lactams and carbapenems are effective against gram-negative rods and anaerobes, achieve therapeutic levels rapidly, and have low toxicity in the absence of penicillin allergy. Second generation cephalosporins (e.g. cefoxitin and cefotetan) remain useful in surgical prophylaxis and treatment of mild community-acquired pneumonia, but limitations in their spectra and antimicrobial resistance restrict their utility in more serious infections. The fourth generation cephalosporins are also effective, but should be combined with other antimicrobials such as metronidazole for adequate anaerobic coverage. Preliminary data on new fluoroquinolones are scant, but promising results were obtained in one clinical trial. We predict the current trend toward the use of broad-spectrum single agent antimicrobials for therapy of intra-abdominal infection will continue.
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Affiliation(s)
- M E Cinat
- University of California Irvine Medical Center, Orange 92868, USA.
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Abstract
During the last decade improved clinical and microbiological methods have resulted in the realization that most intraabdominal infections involve both aerobic and anaerobic bacteria. Papers on the use of different antimicrobial agents directed against the polymicrobial flora of the infected site have been published. In this paper the use of monobactams and carbapenems for treatment of intraabdominal infections is reviewed. The review is based on data published since 1990. Three hundred forty-four patients participated in three trials where aztreonam combined with clindamycin was compared with other antimicrobial agents for treatment of intraabdominal infections. Eighty-six percent of the patients receiving aztreonam plus clindamycin were cured/improved, while 83% of the patients receiving the comparative drugs had favorable outcomes. Eleven trials compared imipenem/cilastatin versus other antimicrobial combinations for therapy of intraabdominal infections. One thousand three hundred seventy-five patients were evaluated in the trials. Eighty percent of patients treated with imipenem/cilastatin had favorable outcomes, while 81% of the patients receiving the comparative drugs were cured/improved. Nine studies including 1,205 patients for evaluation of meropenem versus other antimicrobial agents in the treatment of intraabdominal infections have been published. Cure/improvement was seen in 96% of the patients treated with meropenem and in 91% receiving the comparative drugs. One trial has been published comparing biapenem with imipenem/cilastatin for treatment of intraabdominal infections. Eighty-three patients participated, 65% of the patients in the biapenem group were cured/improved and 68% in the imipenem/cilastatin group.
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Affiliation(s)
- B Brismar
- Division for Anesthesiology, Day Surgery, Emergency Medicine, Operating Theaters and Radiology, Karolinska Institutet, Huddinge University Hospital, Sweden
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Donahue PE, Smith DL, Yellin AE, Mintz SJ, Bur F, Luke DR. Trovafloxacin in the treatment of intra-abdominal infections: results of a double-blind, multicenter comparison with imipenem/cilastatin. Trovafloxacin Surgical Group. Am J Surg 1998; 176:53S-61S. [PMID: 9935258 DOI: 10.1016/s0002-9610(98)00221-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trovafloxacin, a new broad-spectrum fourth-generation quinolone, has in vitro activity against most gram-negative and gram-positive anaerobes and aerobes. Trovafloxacin is available as both an intravenous formulation, alatrofloxacin, and a single daily oral tablet. Excellent tissue pharmacokinetics and oral bioavailability suggest usefulness in the treatment of complicated intra-abdominal infections. Thus, the efficacy of alatrofloxacin followed by oral trovafloxacin was compared with the standard regimen of intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in this prospective, multicenter, double-blind trial. METHODS Patients were randomized to receive either 300 mg alatrofloxacin daily followed by 200 mg oral trovafloxacin daily or 1 g imipenem/cilastatin intravenously thrice daily followed by 500 mg oral amoxicillin/clavulanic acid thrice daily for up to 14 days following surgical intervention of a documented intra-abdominal infection. Efficacy was assessed at the end of therapy and at follow-up (day 30). RESULTS At the end of the study, cure or improvement occurred in 83% (129/156) and 84% (127/152) of clinically evaluable patients in the trovafloxacin and comparative groups, respectively. Pathogen eradication rates, adverse-event profiles, and significant laboratory abnormalities were comparable between groups. CONCLUSION Intravenous alatrofloxacin with or without oral trovafloxacin was as effective as intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in complicated intra-abdominal infections.
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Affiliation(s)
- P E Donahue
- Cook County Hospital, Chicago, Illinois 60612, USA
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