Risk factors for mortality in postoperative peritonitis in critically ill patients

Microbiological profile of patients treated for postoperative peritonitis: temporal trends 1999-2019

BACKGROUND

Temporal changes in the microbiological resistance profile have been reported in several life-threatening infections. However, no data have ever assessed this issue in postoperative peritonitis (POP). Our purpose was to assess the rate of multidrug-resistant organisms (MDROs) in POP over a two-decade period and to analyse their influence on the adequacy of empirical antibiotic therapy (EAT).

METHODS

This retrospective monocentric analysis (1999-2019) addressed the changes over time in microbiologic data, including the emergence of MDROs and the adequacy of EAT for all intensive care unit adult patients treated for POP. The in vitro activities of 10 antibiotics were assessed to determine the most adequate EAT in the largest number of cases among 17 antibiotic regimens in patients with/without MDRO isolates. Our primary endpoint was to determine the frequency of MDRO and their temporal changes. Our second endpoint assessed the impact of MDROs on the adequacy of EAT per patient and their temporal changes based on susceptibility testing. In this analysis, the subgroup of patients with MDRO was compared with the subgroup of patients free of MDRO.

RESULTS

A total of 1,318 microorganisms were cultured from 422 patients, including 188 (45%) patients harbouring MDROs. The growing proportions of MDR Enterobacterales were observed over time (p = 0.016), including ESBL-producing strains (p = 0.0013), mainly related to Klebsiella spp (p < 0.001). Adequacy of EAT was achieved in 305 (73%) patients. Decreased adequacy rates were observed when MDROs were cultured [p = 0.0001 vs. MDRO-free patients]. Over the study period, decreased adequacy rates were reported for patients receiving piperacillin/tazobactam in monotherapy or combined with vancomycin and imipenem/cilastatin combined with vancomycin (p < 0.01 in the three cases). In patients with MDROs, the combination of imipenem/cilastatin + vancomycin + amikacin or ciprofloxacin reached the highest adequacy rates (95% and 91%, respectively) and remained unchanged over time.

CONCLUSIONS

We observed high proportions of MDRO in patients treated for POP associated with increasing proportions of MDR Enterobacterales over time. High adequacy rates were only achieved in antibiotic combinations involving carbapenems and vancomycin, while piperacillin/tazobactam is no longer a drug of choice for EAT in POP in infections involving MDRO.

Clarithromycin-Loaded Submicron-Sized Carriers: Pharmacokinetics and Pharmacodynamic Evaluation

The current study aims to improve clarithromycin bioavailability and effectiveness in complicated intra-abdominal infection management. Therefore, clarithromycin-loaded submicron dual lipid carriers (CLA-DLCs) were developed via hot high shear homogenization technique and evaluated for colloidal parameters, release behavior, stability study, and in-vitro antibiofilm activity. Bioavailability and therapeutic efficacy of optimized formulation on hampering cytokines storm induction was determined in E. coli-induced peritonitis. The developed CLA-DLCs (particle size 326.19 ± 24.14 nm, zeta potential -31.34 ± 2.81 mV, and entrapment efficiency 85.78 ± 4.01%) exhibited smooth spherical shapes and sustained in vitro release profiles. Long-term stability study of optimized CLA-DLCs ensured maintenance of colloidal parameters for 1 year at room temperature. In vitro antimicrobial studies revealed 3.43-fold higher anti-biofilm activity of CLA-DLCs compared with clarithromycin. In addition, the relative bioavailability of CLA-DLCs was enhanced 5.89-fold compared to pure drug in rats. The remarkable decrease in microbial burden in blood as well as tissues, along with oxidative stress markers (lipid peroxidation, myeloperoxidase activity, and carbonylated protein level) and immunological markers (total leukocyte count, neutrophil migration, NO, TNF-, and IL-6) on treatment with CLA-DLCs enhanced the survival in a rat model of peritonitis compared with the pure drug and untreated groups. In conclusion, CLA-DLCs hold promising potential in management of intra-abdominal infections and prevention of associated complications.

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.

Severe secondary peritonitis: impact of inappropriate initial antimicrobial therapy on prognosis and potential carbapenem-sparing

BACKGROUND

Initiation of antimicrobial therapy (IAT) with broad-spectrum antibiotics is usual in Intensive Care Unit (ICU) patients with secondary peritonitis. Carbapenems are widely proposed by recent guidelines contrasting with current antibiotic stewardship policies of carbapenem-sparing. However, prognosis of inappropriate IAT remains unclear in these patients and broad-spectrum antibiotics are probably overused. We aimed to assess the role of inappropriate IAT in ICU patients with secondary peritonitis and the use of carbapenems in our IAT regimens.

METHODS

We performed a retrospective analysis during a six-year period including 131 ICU patients with secondary peritonitis. We collected data concerning comorbidities, source and severity of peritonitis, management of IAT, peritoneal samples and outcome.

RESULTS

Forty-one patients presented with community acquired peritonitis (CAP) and 90 with postoperative peritonitis (POP). Thirty-seven (28.2%) patients died during ICU stay. IAT was inappropriate in 35 (26.7%) patients. Inappropriate IAT was not associated with reduced survival with respectively 26 (27%) deaths when IAT was adequate and 11 (31.4%) deaths when IAT was inadequate (P=0.87). Inappropriate IAT was not associated with the need of re-operation and duration of ICU stay. Carbapenems were delivered in 29 patients but were only necessary for eight patients without alternative treatment.

CONCLUSIONS

In our study, inappropriate IAT was not associated with a worse prognosis and carbapenems were overused. Extensive delivery of carbapenems proposed by recent guidelines could be reconsidered in the management of these patients.

Manejo del abdomen abierto en el paciente crítico en un centro de nivel III de Popayán

Introducción. El abdomen abierto es un recurso útil para el tratamiento de pacientes con patología abdominal compleja, con potencial de complicaciones. El objetivo de este estudio fue adaptar la guía de World Society of Emergency Surgery (WSES) 2018, en un hospital de nivel III de atención de la ciudad de Popayán, Colombia, y comparar los resultados obtenidos con los previos a su implementación. Métodos. Estudio cuasi-experimental en dos mediciones de pacientes con abdomen abierto y estancia en cuidado crítico, durante los meses de abril a octubre de los años 2018 y 2019, antes y después de la adaptación con el personal asistencial de la guía de práctica clínica WSES 2018. Se utilizó estadística descriptiva, prueba de Chi cuadrado y se empleó el software SPSS V.25. Resultados. Se incluyeron 99 pacientes críticos, con una edad media de 53,2 años, con indicación de abdomen abierto por etiología traumática en el 28,3 %, infecciosa no traumática en el 32,3 % y no traumática ni infecciosa en el 37,4 %. La mortalidad global fue de 25,3 %, de los cuales, un 68 % se debieron a causas ajenas a la patología abdominal. Las complicaciones postoperatorias se presentaron en 10 pacientes con infección de sitio operatorio y 9 pacientes con fístula enterocutánea. El uso del doble Viaflex se implementó en un 63,6 %, logrando un cierre de la pared abdominal en el 79,8 % de los casos (p=0,038). Conclusión. El abdomen abierto requiere de un abordaje multidisciplinar. El uso de doble Viaflex es una herramienta simple y efectiva. La implementación de la guía disminuyó el porcentaje de mortalidad, los días de abdomen abierto y la estancia en cuidados intensivos.

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.

Single-Center Retrospective Analysis of the Outcomes of Patients Undergoing Staged Peritoneal Lavage for Secondary Peritonitis

Background

Secondary peritonitis is associated with high rates of morbidity and mortality. Data on the effect of staged re-laparotomy or re-laparoscopy as a surgical option in the management of abdominal sepsis due to secondary peritonitis are limited and conflicting. Herein, we report the outcomes of patients undergoing staged peritoneal lavage (SPL) for secondary peritonitis in our department.

Methods

This is a single-center retrospective analysis of the data of patients undergoing SPL for secondary peritonitis. SPL was performed via either re-laparotomy or re-laparoscopy. The simplified acute physiology score (SAPS II) was calculated at the time of the initial operation and for each SPL. The end points of interest included: the evolution of sepsis characterized by the SAPS II score, the mortality rate and the rate of definitive abdominal wall closure.

Results

The data of 74 patients with a median age of 73 years requiring at least one SPL between 2012 and 2019 were analyzed. The median number of SPL performed was three (range 1–12). A sequential drop of SAPS II score from 41 at the initial procedure to 32 at the third SPL was documented. The overall mortality rate was 16.2%, definitive abdominal closure was achieved in all surviving patients and the median length of stay was 17.5d

Conclusion

Staged re-laparotomy or re-laparoscopy with peritoneal lavage may reduce the severity of peritonitis and reduce the risk of mortality in patients with abdominal sepsis. Maintaining the abdominal wall under constant retraction using a rigid mesh while creating an open abdomen is a crucial step in achieving definite abdominal wall closure. Thus, staged peritoneal lavage may be a good surgical option for selected patients with peritonitis.

Identification of risk factors for recurrent secondary septic peritonitis following initial surgical treatment of secondary septic peritonitis in dogs

OBJECTIVES

To report the incidence of and risk factors for development of recurrent secondary septic peritonitis (RSSP) in dogs. To report the outcome of dogs treated surgically for RSSP.

DESIGN

Retrospective study.

SETTING

University teaching hospital.

ANIMALS

One hundred forty-nine client-owned dogs treated surgically for secondary septic peritonitis (SSP).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

The medical records database was searched for dogs that underwent surgery to treat SSP. Of 149 dogs that met the inclusion criteria, 15 (10.1%) dogs developed RSSP following surgery and 134 (89.9%) did not. Dogs with RSSP had significantly lower albumin prior to the first surgery to treat secondary septic peritonitis (SPsx1) (median 18 g/L [1.8 g/dL] vs 22 g/L [2.2 g/dL], P = 0.005) and significantly higher PCV prior to SPsx1 (median 52% vs 45%, P = 0.028). Dogs with septic peritonitis of gastrointestinal (GI) origin were significantly more likely to develop recurrent peritonitis than those with sepsis from a non-GI source (odds ratio [OR], 4.4, 95% CI: 0.95-20, P = 0.041). Of dogs with sepsis of GI origin, those with sepsis due to a foreign body were significantly more likely to develop RSSP than those with GI sepsis from a non-foreign body cause (OR, 7.2, 95% CI: 1.6-43, P = 0.0018). Of the 15 dogs in the RSSP group, 8 were euthanized without further treatment. Relaparotomy was performed in the remaining 7 cases; 3 of these (42.9%) survived.

CONCLUSIONS

There was a 10.1% rate of RSSP following SPsx1. Preoperative albumin was significantly lower and preoperative PCV was significantly higher in dogs that developed recurrence. Dogs with GI sepsis were at increased risk of recurrence and, among dogs with GI sepsis, the presence of a foreign body was an additional risk factor for recurrence.

Outcome and Adequacy of Empirical Antibiotherapy in Post-Operative Peritonitis: A Retrospective Study

Background: Empirical antibiotherapy (EA) should target all bacteria in post-operative peritonitis (PP). Nevertheless, recent studies failed to prove a link between adequacy of EA and prognosis of PP. We sought to confirm this loss of association between adequate EA and prognosis and to analyze the evolution of patients' characteristics and antimicrobial strategies. Methods: This is was retrospective study. Patients with a positive fungal culture were excluded. The cohort was divided into two time periods. Data of survivors and non-survivors were compared within each time period. Differences between the two periods were assessed. A multivariable analysis searched for parameters associated with a higher hospital mortality rate. Results: Two hundred fifty-one patients were included, with 92 patients in the first period (P1) and 152 patients in the second period (P2). Inadequate EA was associated with a worse outcome only in P1. The multivariable analysis in the whole cohort showed that inadequate EA was associated with a higher mortality rate. When the differences noticed between the two periods were entered in the model (presence of resistant gram-positive cocci and EA comprising glycopeptides), inadequate EA was no longer associated with worse outcome. In P1, the most severe patients had more resistant bacteria, hence, had a higher rate of inadequate EA. This artifact disappeared in P2, during which broader antibiotherapies with triple EA were more often prescribed for the most severe patients. Conclusion: This study showed that the link between inadequate EA and outcome of patients with PP was at least partly artifactual in older studies.

Epidemiology and outcomes of source control procedures in critically ill patients with intra-abdominal infection

PURPOSE

To describe the characteristics and procedural outcomes of source control interventions among Intensive Care Unit (ICU) patients with severe intra-abdominal-infection (IAI).

MATERIAL AND METHODS

We identified consecutive patients with suspected IAI in whom a source control intervention had been performed in two tertiary ICUs in the Netherlands, and performed retrospective in-depth case reviews to evaluate procedure type, diagnostic yield, and adequacy of source control after 14 days.

RESULTS

A total of 785 procedures were observed among 353 patients, with initial interventions involving 266 (75%) surgical versus 87 (25%) percutaneous approaches. Surgical index procedures typically involved IAI of (presumed) gastrointestinal origin (72%), whereas percutaneous index procedures were mostly performed for infections of the biliary tract/pancreas (50%) or peritoneal cavity (33%). Overall, 178 (50%) patients required multiple interventions (median 3 (IQR 2-4)). In a subgroup of 236 patients having their first procedure upon ICU admission, effective source control was ultimately achieved for 159 (67%) subjects. Persistence of organ failure was associated with inadequacy of source control at day 14, whereas trends in inflammatory markers were non-predictive.

CONCLUSIONS

Approximately half of ICU patients with IAI require more than one intervention, yet successful source control is eventually achieved in a majority of cases.

Postoperative Peritonitis After Digestive Tract Surgery: Surgical Management and Risk Factors for Morbidity and Mortality, a Cohort of 191 Patients

BACKGROUND

Postoperative peritonitis (POP) following gastrointestinal surgery is associated with significant morbidity and mortality, with no clear management option proposed. The aim of this study was to report our surgical management of POP and identify pre- and perioperative risk factors for morbidity and mortality.

METHODS

All patients with POP undergoing relaparotomy in our department between January 2004 and December 2013 were included. Pre- and perioperative data were analyzed to identify predictors of morbidity and mortality.

RESULTS

A total of 191 patients required relaparotomy for POP, of which 16.8% required >1 reinterventions. The commonest cause of POP was anastomotic leakage (66.5%) followed by perforation (20.9%). POP was mostly treated by anastomotic takedown (51.8%), suture with derivative stoma (11.5%), enteral resection and stoma (12%), drainage of the leak (8.9%), stoma on perforation (8.4%), duodenal intubation (7.3%) or intubation of the leak (3.1%). The overall mortality rate was 14%, of which 40% died within the first 48 h. Major complications (Dindo-Clavien > 2) were seen in 47% of the cohort. Stoma formation occurred in 81.6% of patients following relaparotomy. Independent risk factors for mortality were: ASA > 2 (OR = 2.75, 95% CI = 1.07-7.62, p = 0.037), multiorgan failure (MOF) (OR = 5.22, 95% CI = 2.11-13.5, p = 0.0037), perioperative transfusion (OR = 2.7, 95% CI = 1.05-7.47, p = 0.04) and upper GI origin (OR = 3.55, 95% CI = 1.32-9.56, p = 0.013). Independent risk factors for morbidity were: MOF (OR = 2.74, 95% CI = 1.26-6.19, p = 0.013), upper GI origin (OR = 3.74, 95% CI = 1.59-9.44, p = 0.0034) and delayed extubation (OR = 0.27, 95% CI = 0.14-0.55, p = 0.0027).

CONCLUSION

Mortality following POP remains a significant issue; however, it is decreasing due to effective and aggressive surgical intervention. Predictors of poor outcomes will help tailor management options.