The Predictive Role of Procalcitonin On the Treatment of Intra-Abdominal Infections

Managing the Open Abdomen: Selecting an Appropriate Treatment Strategy

Significance: The laparotomy is a common surgical procedure with a wide range of indications. Ideally, once the goals of surgery were achieved, the incision edges could then be approximated and the abdomen primarily closed. However, in some circumstances, it may be impossible to achieve primary closure, and instead the abdomen is intentionally left open. This review discusses the indications and objectives for the open abdomen (OA), summarizes the most common techniques for temporary abdominal closure, and illustrates treatment algorithms grounded in the current recommendations from specialty experts. Recent Advances: Still a relatively young technique, multiple strategies, and technologies have emerged to manage the OA. So too have the recommendations evolved, based on updated classifications that take wound characteristics into account. Recent studies have also brought greater clarity on recommendations for managing infection and malnutrition to support improved clinical outcomes. Critical Issues: The status of the OA can change rapidly depending on the patient's condition, the wound quality, and many other factors. Thus, there is a significant need for comprehensive treatment strategies that can be adapted to these developing circumstances. Future Directions: Treatment recommendations should be continuously updated as new technologies are introduced and old techniques fall out of use.

Procalcitonin-guided antibiotic therapy may shorten length of treatment and may improve survival-a systematic review and meta-analysis

BACKGROUND

Appropriate antibiotic (AB) therapy remains a challenge in the intensive care unit (ICU). Procalcitonin (PCT)-guided AB stewardship could help optimize AB treatment and decrease AB-related adverse effects, but firm evidence is still lacking. Our aim was to compare the effects of PCT-guided AB therapy with standard of care (SOC) in critically ill patients.

METHODS

We searched databases CENTRAL, Embase and Medline. We included randomized controlled trials (RCTs) comparing PCT-guided AB therapy (PCT group) with SOC reporting on length of AB therapy, mortality, recurrent and secondary infection, ICU length of stay (LOS), hospital LOS or healthcare costs. Due to recent changes in sepsis definitions, subgroup analyses were performed in studies applying the Sepsis-3 definition. In the statistical analysis, a random-effects model was used to pool effect sizes.

RESULTS

We included 26 RCTs (n = 9048 patients) in the quantitative analysis. In comparison with SOC, length of AB therapy was significantly shorter in the PCT group (MD - 1.79 days, 95% CI: -2.65, - 0.92) and was associated with a significantly lower 28-day mortality (OR 0.84, 95% CI: 0.74, 0.95). In Sepsis-3 patients, mortality benefit was more pronounced (OR 0.46 95% CI: 0.27, 0.79). Odds of recurrent infection were significantly higher in the PCT group (OR 1.36, 95% CI: 1.10, 1.68), but there was no significant difference in the odds of secondary infection (OR 0.81, 95% CI: 0.54, 1.21), ICU and hospital length of stay (MD - 0.67 days 95% CI: - 1.76, 0.41 and MD - 1.23 days, 95% CI: - 3.13, 0.67, respectively).

CONCLUSIONS

PCT-guided AB therapy may be associated with reduced AB use, lower 28-day mortality but higher infection recurrence, with similar ICU and hospital length of stay. Our results render the need for better designed studies investigating the role of PCT-guided AB stewardship in critically ill patients.

Management of Intra-Abdominal Infections: The Role of Procalcitonin

Patients with intra-abdominal sepsis suffer from significant mortality and morbidity. The main pillars of treatment for intra-abdominal infections are (1) source control and (2) early delivery of antibiotics. Antibiotic therapy should be started as soon as possible. However, the duration of antibiotics remains a matter of debate. Prolonged antibiotic delivery can lead to increased microbial resistance and the development of nosocomial infections. There has been much research on biomarkers and their ability to aid the decision on when to stop antibiotics. Some of these biomarkers include interleukins, C-reactive protein (CRP) and procalcitonin (PCT). PCT's value as a biomarker has been a focus area of research in recent years. Most studies use either a cut-off value of 0.50 ng/mL or an >80% reduction in PCT levels to determine when to stop antibiotics. This paper performs a literature review and provides a synthesized up-to-date global overview on the value of PCT in managing intra-abdominal infections.

Use of Procalcitonin to Guide Discontinuation of Antimicrobial Therapy in Patients with Persistent Intra-Abdominal Collections: A Case Series

Objective

Limited evidence exists for the use of procalcitonin (PCT) to guide the duration of antimicrobial therapy in patients with intra-abdominal abscesses (IAA). In this case series, we describe clinical presentations and outcomes using PCT to guide cessation of antimicrobial therapy in patients with persistent IAA who exhibited clinical improvement.

Methods

A retrospective analysis of patients with IAA who had PCT levels available to review was performed in a tertiary academic teaching institution in the United States between 2017 and 2018. Demographics, clinical characteristics, and outcomes were obtained from the medical records. Patients were followed up for a minimum of 180 days after completion of antimicrobial therapy to determine if evidence of recurrence or mortality was present.

Results

We identified four patients with IAA. They underwent early drainage of the source of infection and received empiric antimicrobial therapy according to individual risk factors and clinical scenarios. Antimicrobials were discontinued after clinical and radiographic improvement and evidence of normal PCT levels, regardless of the persistence of fluid collections. No evidence of recurrence or mortality was observed during the follow-up period.

Conclusions

We found PCT to be a useful aid in the medical decision-making process to safely discontinue antimicrobial therapy in a series of patients with persistent intra-abdominal collections despite early drainage and appropriate course of antimicrobial therapy.

Abdominal Compartment Syndrome in Critically Ill Patients

BACKGROUND

Abdominal compartment syndrome patients suffer severe obstacles such as kidney failure and shock. To evade further complications, identifying the abdominal compartment syndrome (ACS) and Intra-abdominal hypertension (IAH), in critically ill individuals and hospitalised in the intensive care unit (ICU) is obligated.

AIM

The current study intended to study the abdominal compartment syndrome and the concomitant risk factors among hospitalised patients in ICU, by using the Intra-abdominal pressure test.

MATERIAL AND METHODS

One hundred and twenty-five hospitalised patients at ICU entered the current survey. Abdominal pressure was measured by standard intravesical technique. The SPSS 21 analysed the preoperative and intraoperative factors such as demographic records and comorbidities.

RESULTS

Seventy-three (58.4%) participants were males and 52 (41.6%) were women in the mean age of 55.1 ± 18.3 years. Eighty-nine patients (71.2%) showed normal intra-abdominal pressure since 31 patients (24.8%), and 5 patients (4%) developed IAH and ACS. The intra-abdominal pressure (IAP) applied to Glasgow Coma Scale (GCS), Acute Physiology, shock, Systemic Inflammatory Response Syndrome (SIRS), central venous oxygen saturation and Chronic Health Evaluation (APACHE II) score (P < 0.05). Patients with high IAP have shown a higher mortality frequency, compared to others (P < 0.05).

CONCLUSION

Current findings showed a correlation between IAP hospitalised patients in ICU and shock, SIRS, APACHE II, central venous oxygen saturation and GCS. Intra-abdominal pressure test, as a valuable prognosis test for the abdominal compartment syndrome (ACS) and Intra-abdominal hypertension (IAH), may offer better results when added to the routine medical checkup of ICU patients.

Procalcitonin and Proinflammatory Cytokines in Early Diagnosis of Bacterial Infections after Bronchoscopy

BACKGROUND:

Fiberoptic bronchoscopy (FOB) guided bronchoalveolar lavage (BAL) remains as the chief diagnostic tool in respiratory disorders. 1.2-16% of patients frequently experience fever after bronchoscopy. To exclude the need for multiple antibiotic prescribing in patients with post-bronchoscopy fever, the presence of the self-limiting inflammatory responses should be excluded.

AIM:

The current study was conducted to test the serum of patients undergoing bronchoscopy for some proinflammatory cytokines including Tumor Necrosis Factor-alpha (TNF-ɑ), Interleukin-1beta (IL-1β), Interleukin-8 (IL-8) and Interleukin-6 (IL-6) and the value of Procalcitonin (PCT).

MATERIAL AND METHODS:

Current case-control study was conducted at the National Research Institute of Tuberculosis and Lung Disease in Iran. Nineteen patients (48.72%) that attended with a reasonable sign for a diagnostic bronchoscopy from January 2016 to December 2017 were included in the case group. The control group consisted of 20 patients who underwent a simple bronchoscopy and without FOB-BAL. The laboratory findings for PCT concentrations and cytokine levels in the three serum samples (before FOB-BAL (t0), after 6 hr. (t1), and at 24 hr. past (t2) FOB-BAL) were compared between two groups.

RESULTS:

The frequency of post-bronchoscopy fever was 5.12, and the prevalence of post-bronchoscopy infectious fever was 2.56%. PCT level was considerably higher in the patient with a confirmed bacterial infection when compared to other participants (p-value < 0. 05). Interestingly, IL-8 level in the bacterial infection proven fever patient was higher than in other patients (p < 0.001). IL-8 levels displayed a specificity of 72.7% and a sensitivity of 100%, at the threshold point of 5.820 pg/ml. PCT levels had a specificity of 84% and a sensitivity of 81%, at the threshold point of 0.5 ng/ml.

CONCLUSION:

The present findings show that in patients with fever after bronchoscopy, PCT levels and IL-8 levels are valuable indicators for antibiotic therapy, proving adequate proof for bacterial infection. The current findings also illustrate that to monitor the serum levels of PCT and proinflammatory cytokines in the patients undergoing FOB-BAL, the best time is the 24-hour postoperative bronchoscopy.