[Staged approach in the treatment of patients with enterocutaneous fistulae]

OBJECTIVE

To determine an optimal approach in the treatment of patients with intestinal fistulae.

MATERIAL AND METHODS

We have used the above-mentioned algorithm in the treatment of 46 patients. The majority of patients (n=44, 96%) were transferred under supervision of our multidisciplinary team with severe water-electrolyte disturbances and signs of secondary protein-energy malnutrition (PEM) that required complex combined nutritional support. A two-stage approach was applied in all cases. The first one was conservative and included correction and prevention of infectious complications, nutritional and metabolic therapy, local wound treatment, and anatomical assessment of the fistula. The second stage was reconstructive and implied various reconstructive interventions not earlier than 3 months after formation of the fistula.

RESULTS

Conservative approach was followed by fistula healing in 6 patients, surgery was required in 25 patients. Complications with subsequent redo surgery occurred in 4 cases. In all cases, favorable outcome was noted. All 25 patients were discharged. Three patients refused reconstructive surgery after development of fistula, they were also discharged. Mortality rate was 26% (n=12).

CONCLUSION

A multidisciplinary two-stage approach can significantly improve treatment outcomes in patients with intestinal fistulae.

[Prediction and differentiated approach in the treatment of patients with secondary peritonitis and abdominal sepsis]

OBJECTIVE

To identify the most important high risk criteria for predicting course of disease, as well as optimal preoperative preparation and surgical strategy in patients with secondary peritonitis.

MATERIAL AND METHODS

A prospective study enrolled 43 patients with diffuse secondary peritonitis.

RESULTS

Significant predictors were Charlson's comorbidity index (p=0.001) and SOFA score of organ dysfunction within 3 days after admission. Rapid regression of organ dysfunction (SOFA1 - p=0.0001, SOFA2 - p=0.012, SOFA3 - p=0.017) and reduced time of examination and preoperative preparation (threshold value - 520 min after admission) are predictors of favorable outcome in patients with diffuse secondary peritonitis. There was no reliable correlation between the treatment outcome and preoperative preparation (infusion volume p=0.23, duration p=0.37, absence/presence of antibacterial therapy p=0.26). Elimination or control of infection is the fundamental principle of the management of patients with diffuse secondary peritonitis.

Emergence of carbapenemase-producing Gram-negative bacteria in Saint Petersburg, Russia

The emergence and spread of carbapenemase-producing Gram-negative bacteria represents a serious public health concern. Here we show that of 477 Gram-negative isolates collected from 18 hospitals between November 2011 and February 2013 in Saint Petersburg (Russia), minimum inhibitory concentrations (MICs) were greater than the European Committee on Antimicrobial Susceptibility Testing (EUCAST) epidemiological cut-off value of at least one carbapenem antibiotic in 101 isolates (21.2%). The bla(NDM-1) gene was detected by PCR in 17 Klebsiella pneumoniae and 1 Acinetobacter nosocomialis isolate. Multilocus sequence typing (MLST) revealed that all NDM-1-producing K. pneumoniae isolates belonged to sequence type 340 (ST340) and harboured genes encoding additional β-lactamases; presence of the bla(CTX-M-1-like) gene correlated with aztreonam resistance, whilst its absence correlated with susceptibility. The epidemiological situation in Saint Petersburg can be assessed as regional spread of NDM-1-producers. The bla(KPC-2) gene was detected in two K. pneumoniae isolates (ST258 and ST273) and one Enterobacter cloacae isolate. Two E. cloacae isolates harboured the bla(VIM-4) gene, and one K. pneumoniae (ST395) isolate harboured the bla(OXA-48) gene. In NDM-1-producers, MICs of biapenem were the lowest compared with those of other carbapenems. Most isolates were susceptible to tigecycline and polymyxin, except for one K. pneumoniae isolate that was found to be polymyxin-resistant and one E. cloacae isolate that was tigecycline-resistant. Only one patient with a urinary tract infection caused by KPC-2-producing K. pneumoniae had a history of travel abroad (Southeast Asia). Thus, there is an actual threat of the emergence of an alarming endemic situation with NDM-1-producers in Saint Petersburg.