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Abstract
Le peritoniti corrispondono a un’infiammazione acuta del peritoneo le cui cause più frequenti sono infettive, il più delle volte per perforazione del tubo digerente. Si distinguono le infezioni extraospedaliere e le infezioni nosocomiali, soprattutto postoperatorie. I microrganismi implicati sono quelli della flora digestiva (enterobatteri e anaerobi), ma dei cocchi Gram positivi e dei lieviti possono essere isolati nelle infezioni acquisite in ospedale. Queste patologie sono un’urgenza terapeutica. La diagnosi è, il più delle volte, clinica, con l’aiuto degli esami radiologici. Il trattamento è chirurgico e medico. Il trattamento eziologico si basa sulla chirurgia per individuare ed eliminare la causa dell’infezione, realizzare dei prelievi microbiologici, eseguire una toilette peritoneale e prevenire la recidiva. Il trattamento medico gestisce le conseguenze dell’infezione con la rianimazione perioperatoria e il trattamento antibiotico diretto contro i microrganismi isolati dai prelievi perioperatori. Una terapia antibiotica che non prenda in considerazione tutti i microrganismi isolati e una gestione tardiva sono dei fattori di insuccesso terapeutico, di persistenza dell’infezione e, perfino, di morte. Analogamente, la malattia rimane gravata da una forte mortalità quando insorge in un soggetto anziano, portatore di malattie sottostanti e operato tardivamente, particolarmente quando si tratta di un’infezione postoperatoria. La durata del trattamento è dell’ordine di 7-10 giorni o anche meno, in caso di infezione presa in carico precocemente e in pazienti senza insufficienza.
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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.
Enterococci may increase morbidity and mortality in elderly patients with intra-abdominal infections (IAIs) hospitalized in the intensive care unit (ICU).
A single-centre, retrospective evaluation of an ICU database (1997-2007) of elderly ICU patients (≥75 years) with a severe IAI was performed. Demographics, severity scores, underlying diseases, microbiology and outcomes were recorded. Patients with enterococci isolated in peritoneal fluid (E+ group) were compared with those lacking enterococci in peritoneal fluid (E- group). Stepwise multivariate logistic regression was used to identify independent factors associated with mortality.
One hundred and sixty patients were included (mean ± SD age 82 ± 5 years; n = 72 in the E+ group). The E+ group was more severely ill than the E- group, with higher Simplified Acute Physiologic Score 2 (61 ± 20 versus 48 ± 16, P = 0.0001) and Sequential Organ Failure Assessment scores (8 ± 3 versus 5 ± 3, P = 0.0001), a greater postoperative infection rate (58.3% versus 34.1%, P = 0.01), a higher incidence of inappropriate empirical antimicrobial therapies (33.3% versus 19.3%, P = 0.04), a longer duration of mechanical ventilation (11.8 ± 10.9 versus 7.8 ± 10.2 days, P = 0.02) and greater vasopressor use (7.2 ± 7.1 versus 3.3 ± 4.1 days, P = 0.001). ICU mortality was higher in the E+ group than in the E- group (54.2% versus 38.6%, P = 0.05). In the multivariate analysis, E+ status was independently associated with mortality (odds ratio 2.24; 95% confidence interval 1.06-4.75; P = 0.03).
In severely ill, elderly patients in the ICU for an IAI, the isolation of enterococci was associated with increased disease severity and morbidity and was an independent risk factor for mortality.
Head-to-head comparison of ultrasound and CT accuracy in common diagnoses causing acute abdominal pain.
Consecutive patients with abdominal pain for >2 h and <5 days referred for imaging underwent both US and CT by different radiologists/radiological residents. An expert panel assigned a final diagnosis. Ultrasound and CT sensitivity and predictive values were calculated for frequent final diagnoses. Effect of patient characteristics and observer experience on ultrasound sensitivity was studied.
Frequent final diagnoses in the 1,021 patients (mean age 47; 55% female) were appendicitis (284; 28%), diverticulitis (118; 12%) and cholecystitis (52; 5%). The sensitivity of CT in detecting appendicitis and diverticulitis was significantly higher than that of ultrasound: 94% versus 76% (p < 0.01) and 81% versus 61% (p = 0.048), respectively. For cholecystitis, the sensitivity of both was 73% (p = 1.00). Positive predictive values did not differ significantly between ultrasound and CT for these conditions. Ultrasound sensitivity in detecting appendicitis and diverticulitis was not significantly negatively affected by patient characteristics or reader experience.
CT misses fewer cases than ultrasound, but both ultrasound and CT can reliably detect common diagnoses causing acute abdominal pain. Ultrasound sensitivity was largely not influenced by patient characteristics and reader experience.
Foreign travel has been suggested to be a risk factor for the acquisition of extended-spectrum beta-lactamase (ESBL)-producing
Enterobacteriaceae. To our knowledge, this has not previously been demonstrated in a prospective study. Healthy volunteers traveling outside
Northern Europe were enrolled. Rectal swabs and data on potential travel-associated risk factors were collected before and
after traveling. A total of 105 volunteers were enrolled. Four of them did not complete the study, and one participant carried
ESBL-producing Escherichia coli before travel. Twenty-four of 100 participants with negative pretravel samples were colonized with ESBL-producing Escherichia coli after the trip. All strains produced CTX-M enzymes, mostly CTX-M-15, and some coproduced TEM or SHV enzymes. Coresistance
to several antibiotic subclasses was common. Travel to India was associated with the highest risk for the acquisition of ESBLs
(88%; n = 7). Gastroenteritis during the trip was an additional risk factor (P = 0.003). Five of 21 volunteers who completed the follow-up after 6 months had persistent colonization with ESBLs. This is
the first prospective study demonstrating that international travel is a major risk factor for colonization with ESBL-producing
Enterobacteriaceae. Considering the high acquisition rate of 24%, it is obvious that global efforts are needed to meet the emergence and spread
of CTX-M enzymes and other antimicrobial resistances.
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.
The main objective was to determine risk factors for presence of multidrug resistant bacteria (MDR) in postoperative peritonitis (PP) and optimal empirical antibiotic therapy (EA) among options proposed by Infectious Disease Society of America and the Surgical Infection Society guidelines.
One hundred patients hospitalised in the intensive care unit (ICU) for PP were reviewed. Clinical and microbiologic data, EA and its adequacy were analysed. The in vitro activities of 9 antibiotics in relation to the cultured bacteria were assessed to propose the most adequate EA among 17 regimens in the largest number of cases.
A total of 269 bacteria was cultured in 100 patients including 41 episodes with MDR. According to logistic regression analysis, the use of broad-spectrum antibiotic between initial intervention and reoperation was the only significant risk factor for emergence of MDR bacteria (odds ratio (OR) = 5.1; 95% confidence interval (CI) = 1.7 - 15; P = 0.0031). Antibiotics providing the best activity rate were imipenem/cilastatin (68%) and piperacillin/tazobactam (53%). The best adequacy for EA was obtained by combinations of imipenem/cilastatin or piperacillin/tazobactam, amikacin and a glycopeptide, with values reaching 99% and 94%, respectively. Imipenem/cilastin was the only single-drug regimen providing an adequacy superior to 80% in the absence of broad spectrum antibiotic between initial surgery and reoperation.
Interval antibiotic therapy is associated with the presence of MDR bacteria. Not all regimens proposed by Infectious Disease Society of America and the Surgical Infection Society guidelines for PP can provide an acceptable rate of adequacy. Monotherapy with imipenem/cilastin is suitable for EA only in absence of this risk factor for MDR. For other patients, only antibiotic combinations may achieve high adequacy rates.
This prospective non-interventional study investigated the risk factors for multidrug-resistant bacteria (MDRB) in patients with post-operative peritonitis (POP), to provide guidance for empirical antimicrobial therapy.
All consecutive patients, >15 years old, admitted to a surgical intensive care unit (ICU) between September 2006 and January 2009 for a first episode of POP were included. Antibiotic susceptibilities of microorganisms recovered from blood cultures and peritoneal fluid were determined by disc diffusion. Amoxicillin/clavulanic acid, ticarcillin/clavulanic acid, piperacillin/tazobactam, cefotaxime, ceftazidime, cefepime, imipenem, gentamicin, amikacin and ciprofloxacin were tested against Gram-negative bacteria, and oxacillin, amoxicillin, vancomycin, gentamicin and erythromycin were tested against aerobic Gram-positive bacteria. Results were reported as susceptible or resistant.
MDRB were isolated from 20/115 (17%) patients. In univariate analysis, use of antimicrobial therapy during the 3 months prior to hospitalization and a long duration between hospital admission or first operation and relaparotomy were significantly associated with MDRB recovery. In multivariate analysis, only antimicrobial treatment in the 3 months preceding hospitalization and duration between first operation and relaparotomy were independent risk factors for MDRB [odds ratio (OR) = 5.80, 95% confidence interval (95% CI) = 1.99-16.91 and OR = 1.10, 95% CI = 1.02-1.19, respectively]. No MDRB were found when the delay between the first operation and relaparotomy was <5 days. POP severity, non-surgical and surgical complications, hospital and ICU length of stay, and mortality were similar in patients with and without MDRB.
Our results suggest that broad-spectrum antibiotics should be used in ICU patients with POP who have received antimicrobial therapy in the 3 months prior to hospitalization, or with >5 days between the first operation and relaparotomy.
The risk factors associated with poor outcome in generalized peritonitis are still debated. Our aim was to analyze clinical and bacteriological factors associated with the occurrence of shock and mortality in patients with secondary generalized peritonitis.
This was a prospective observational study involving 180 consecutive patients with secondary generalized peritonitis (community-acquired and postoperative) at a single center. We recorded peri-operative occurrence of septic shock and 30-day survival rate and analyzed their associations with patients characteristics (age, gender, SAPS II, liver cirrhosis, cancer, origin of peritonitis), and microbiological/mycological data (peritoneal fluid, blood cultures).
Frequency of septic shock was 41% and overall mortality rate was 19% in our cohort. Patients with septic shock had a mortality rate of 35%, versus 8% for patients without shock. Septic shock occurrence and mortality rate were not different between community-acquired and postoperative peritonitis. Age over 65, two or more microorganisms, or anaerobes in peritoneal fluid culture were independent risk factors of shock. In the subgroup of peritonitis with septic shock, biliary origin was independently associated with increased mortality. In addition, intraperitoneal yeasts and Enterococci were associated with septic shock in community-acquired peritonitis. Yeasts in the peritoneal fluid of postoperative peritonitis were also an independent risk factor of death in patients with septic shock.
Unlike previous studies, we observed no difference in incidence of shock and prognosis between community-acquired and postoperative peritonitis. Our findings support the deleterious role of Enterococcus species and yeasts in peritoneal fluid, reinforcing the need for prospective trials evaluating systematic treatment against these microorganisms in patients with secondary peritonitis.
The level of inter-observer agreement of abdominal computed tomography (CT) in unselected patients presenting with acute abdominal pain at the Emergency Department (ED) was evaluated. Two hundred consecutive patients with acute abdominal pain were prospectively included. Multi-slice CT was performed in all patients with intravenous contrast medium only. Three radiologists independently read all CT examinations. They recorded specific radiological features and a final diagnosis on a case record form. We calculated the proportion of agreement and kappa values, for overall, urgent and frequently occurring diagnoses. The mean age of the evaluated patients was 46 years (range 19-94), of which 54% were women. Overall agreement on diagnoses was good, with a median kappa of 0.66. Kappa values for specific urgent diagnoses were excellent, with median kappa values of 0.84, 0.90 and 0.81, for appendicitis, diverticulitis and bowel obstruction, respectively. Abdominal CT has good inter-observer agreement in unselected patients with acute abdominal pain at the ED, with excellent agreement for specific urgent diagnoses as diverticulitis and appendicitis.
The EBIIA (Etude épidémiologique Bactério-clinique des Infections Intra-Abdominales) study was designed to describe the clinical, microbiological and resistance profiles of community-acquired and nosocomial intra-abdominal infections (IAIs).
From January to July 2005, patients undergoing surgery/interventional drainage for IAIs with a positive microbiological culture were included by 25 French centres. The primary endpoint was the epidemiology of the microorganisms and their resistance to antibiotics. Multivariate analysis was carried out using stepwise logistic regression to assess the factors predictive of death during hospitalization.
Three hundred and thirty-one patients (234 community-acquired and 97 nosocomial) were included. The distribution of the microorganisms differed according to the type of infection. Carbapenems and amikacin were the most active agents in vitro against Enterobacteriaceae in both community-acquired and nosocomial infections. Against Pseudomonas aeruginosa, amikacin, imipenem, ceftazidime and ciprofloxacin were the most active agents in community-acquired infections, while imipenem, cefepime and amikacin were the most active in nosocomial cases. Against the Gram-positive bacteria, vancomycin and teicoplanin were the most active in both infections. Against anaerobic bacteria, the most active agents were metronidazole and carbapenems in both groups. Empirical antibiotic therapy adequately targeted the pathogens for 63% of community-acquired and 64% of nosocomial peritonitis. The presence of one or more co-morbidities [odds ratio (OR) = 3.17; P = 0.007], one or more severity criteria (OR = 4.90; P < 0.001) and generalized peritonitis (OR = 3.17; P = 0.006) were predictive of death.
The principal results of EBIIA are a higher diversity of microorganisms isolated in nosocomial infections and decreased susceptibility among these strains. Despite this, the adequacy of treatment is comparable in the two groups.
The aim of this study was to determine the steady-state plasma and peritoneal concentrations of cefotaxime and its metabolite desacetyl-cefotaxime administered by continuous infusion to critically ill patients with secondary peritonitis.
In 11 patients, a continuous infusion of 4 g/24 h of cefotaxime following a bolus of 2 g was evaluated. Plasma and peritoneal levels of cefotaxime and desacetyl-cefotaxime were measured at steady state on days 2 and 3 (plasma) and on day 3 (peritoneal) by HPLC. Results are expressed as means +/- SD.
Total and unbound plasma levels of cefotaxime were 24.0 +/- 21.5 and 20.3 +/- 19.8 mg/L on day 2 and 22.1 +/- 20.7 and 18.9 +/- 19.2 mg/L on day 3, respectively. Total and unbound levels of cefotaxime in the peritoneal fluids were 16.2 +/- 11.5 and 14.3 +/- 10.4 mg/L, respectively. The unbound fraction of plasma cefotaxime was 81.8 +/- 5.9% on day 2 and 82.6 +/- 7.7% on day 3, and the unbound fraction at the peritoneal site was 87.0 +/- 5.5% on day 3. Total and unbound plasma levels of desacetyl-cefotaxime were 9.0 +/- 8.1 and 8.4 +/- 8.1 mg/L on day 2 and 7.6 +/- 7.6 and 7.2 +/- 7.6 mg/L on day 3, respectively. Total and unbound levels of desacetyl-cefotaxime in the peritoneal fluids were 11.9 +/- 11.5 and 10.9 +/- 10.8 mg/L, respectively. The MICs for the enterobacteria recovered ranged from 0.016 to 0.25 mg/L.
Continuous infusion of 4 g/24 h of cefotaxime provided a peritoneal concentration >5x MIC for the recovered Enterobacteriaceae and the susceptibility breakpoint of cefotaxime for facultative Gram-negative bacilli.
In order to compare the clinical and microbiological efficacies and safety of piperacillin plus tazobactam with those of imipenem plus cilastatin, 134 patients with intra-abdominal infections (73 patients with appendicitis) participated in an open randomized comparative multicenter trial. A total of 40 men and 29 women (mean age, 53 years; age range, 18 to 92 years) were enrolled in the piperacillin-tazobactam group and 40 men and 25 women (mean age, 54 years; age range, 16 to 91 years) were enrolled in the imipenem-cilastatin group. The patients received either piperacillin (4 g) and tazobactam (500 mg) every 8 h or imipenem and cilastatin (500 mg each) every 8 h. Both regimens were given by intravenous infusion. A total of 113 patients were clinically evaluable. Of 55 patients who received piperacillin-tazobactam, 50 were clinically cured, while 40 of 58 patients in the imipenem-cilastatin group were clinically cured. The differences were significant (Wilcoxon test; P = 0.005). There were 4 failures or relapses in the piperacillin-tazobactam group and 18 failures or relapses in the imipenem-cilastatin group. The microorganisms isolated were eradicated in similar proportions in the two patient groups. Adverse reactions, mainly gastrointestinal disturbances and nausea, were noted in 13 patients who received piperacillin-tazobactam and in 14 patients who received imipenem-cilastatin. Results of the present study show that piperacillin-tazobactam is effective and safe for the treatment of intra-abdominal infections.
Before operative therapy was generally used, about 90% of all patients with intraabdominal infection died from sepsis. This outcome might regarded the natural course of the disease. When principles of surgical management were established commonly utilized, the mortality dropped below 50% in large series [1]. The improved survival of 40-50% must credited to operative management alone since, during the first three decades of the 20th. century, efficacious antibiotics were not available and effective critical care treatment was not possible.
Fleming discovered penicillin in 1929 [2] and its later introduction into clinical medicine led to dramatic therapeutic improvements in surgical infections [3]; however, in subsequent decades, the mortality risk of intraabdominal infection was not affected by antibiotic therapy and the average mortality reported remained unchanged until the 1970's [4] (Fig. 1). In the past 10 years, better survival rates have been reported. It is difficult, however, to attribute the most recent improvement to one specific therapy because several new supportive techniques for the care of patients with serious intraabdominal infection have been recently introduced. These advances include new operative techniques (Tables 1, 2) [5-30], more potent antimicrobials, new concepts of hemodynamic, respiratory, and renal support guided by direct measurement of cardiac performance, and new radiographic techniques for localizing and treating (nonoperatively) abscess.
Despite advances, mortality from many forms of intraabdominal infection remains unacceptably high. Substantial differences between conventional and more recently developed therapies have not found in randomized prospective studies. It has become apparent that approaches for managing patients profoundly ill from intraabdominal infection requires further critical review that new methods for analyzing the results of various therapeutic interventions must be found. With this background, an international congress on intraabdominal infections was organized in Hamburg in 1987, supported by the Surgical Infection Society (SIS) and the Paul Ehrlich Society. Surgeons from all continents came to review the current status of definitions well statistical techniques and severity-of-illness scoring systems, to allow for more sophisticated analysis of results. Also analyzed were all new innovative operative techniques, which had developed because of the failure of accepted therapies to greatly alter outcome. Additionally, a broad range of subjects were presented on all aspects of intraabdominal infection including diagnosis, pathogenesis, bacteriology, inflammation and immunology, animal models of intraabdominal sepsis, intensive care, multisystem organ failure, antimicrobial therapy, and nonoperative treatment for intraabdominal abscess.
Participants in the session on "Definitions and Risk Factor Analysis and Severity Scoring: Foundation for Research and Clinical Trials" continued the discussion at subsequent meetings. The results of these conferences are presented in the first article of this Progress Symposium.{Knaus} Although the APACHE II score is difficult to assess and is not specific for intraabdominal infections, it was recognized as the most widely accepted prognostic index. While other more specific scores may be easily assessed, and have been validated in large patient populations and shown to exhibit the same prognostic value APACHE II, preference was given to the SlS-modified APACHE scoring system. Its use was recommended for better comparison of critically ill patients and as a baseline reference for future studies. During these discussions, it became obvious that the predictive power of scoring systems is limited and further improvement may not be possible. Other yet unknown techniques may be necessary to accurately measure the biological variances seen with intraabdominal infection.
In the second article of this symposium, the authors address new types of intraabdominal infections now being seen, which are difficult to understand [31, 32], and classified as tertiary peritonitis. During the Hamburg meeting, it was not possible to develop a more practical classification system to include all aspects of this disease such as chemical peritonitis, intraabdominal abscess, spontaneous peritonitis, traumatic peritonitis, serofibrinous peritonitis, tertiary peritonitis, etc. Until a better nosologic answer is found, perhaps the classification of peritonitis given below might be utilized: (Table I) Most surgeons refer to peritonitis as an intraabdominal infection from a perforation of an intestinal organ. Intraabdominal infection and peritonitis, however, are not synonymous. Although commonly used to describe a suppurative intraabdominal process, "peritonitis" actually means inflammation of the peritoneum, or of a part thereof, which may not necessarily be due to infection. The term "intraabdominal infection" implies an infectious disease process and requires identification of the causative infecting microorganism. The body's response to intraabdominal infections is the same as that for peritonitis.
Thus, peritonitis should be regarded as a general class which includes the specific entity, intraabdominal infection. Intraabdominal infections are not solely a local disease, but affect the entire body with subsequent organ system dysfunction. These pathophysiologic responses of the host to the inflammatory and bacterial challenges are addressed in the articles by Hau, Christou, Runcie and Ramsay, and Offenbartl and Bengmark. The important pathogenic issue of adherence of bacteria to peritoneal cells is highlighted in the contribution by Edmiston and associates. Consequences of organ function, although a major issue during the Hamburg congress, are still poorly understood and these five contributions deal with current concepts.
Four further articles address therapeutic issues: the present concepts of antimicrobial therapy, the classical concepts of operative therapy, nonoperative management of intraabdominal abscesses, and experience with the more aggressive operative management of Etappenlavage. During the Hamburg congress, it became obvious that the open abdomen techniques for treatment of advanced diffuse suppurative peritonitis carries a risk of too many complications [6-18]. Planned relaparotomies with various devices for temporary abdominal closure seems to be the answer for the subset of patients with advanced infections
Microbial pathogens within the peritoneal cavity are thought to encounter three categories of host defense mechanisms: (i) removal mechanisms, which occur via diaphragmatic lymphatic absorption; (ii) killing mechanisms, in which host phagocytes act as effector cells; and (iii) sequestration mechanisms due to fibrin trapping and the formation of adhesions between visceral surfaces. We sought to define and quantitate the relative role of the first two components in an experimental rat model of Escherichia coli peritonitis in which fibrinous adhesions do not form. Intraperitoneal challenge with greater than or equal to 2 X 10(8) CFU of viable E. coli led to an initial decline in bacterial numbers followed by ongoing proliferation and greater than 50% mortality. With inocula of less than or equal to 5 X 10(7) CFU, elimination of bacteria occurred after moderate initial proliferation, and no mortality ensued. Nonviable, radiolabeled E. coli organisms were utilized to examine bacterial clearance via translymphatic absorption and phagocytosis. Both processes were extremely rapid, serving to eliminate free bacteria rapidly within the peritoneal cavity. Although macrophages and polymorphonuclear leukocytes within the peritoneal cavity demonstrated similar phagocytic capacities, the predominance of macrophages at the time of the initial bacterial insult led to the conclusion that these cells, in addition to translymphatic absorption, represent the first line of host defenses, acting to eliminate bacteria in the incipient stages of infection.
This chapter focuses on rat polymicrobial peritonitis infection models, which can be classified into three categories: direct intraperitoneal injection, bowel manipulations, and peritoneal implantation. Any strain of rats can be used for this model, although gender may be an important parameter to consider since Weinstein et al. reported an increased toxicity of the inoculum in female Wistar rats. The materials required in this model include anesthetic (preferably injectable), clippers or razor, skin disinfectant, surgical slippers, forceps, syringes and needles (20–23 g), and suture material. The ideal anesthetic agent is a rapidly acting drug (< 5–10 minutes), administered intramuscularly or subcutaneously, with a short duration of action (15–30 minutes), without respiratory depression and satisfactory muscular relaxation. The skin is disinfected with 70% vol./vol, ethanol, but other disinfectants such as isopropanolol or iodine-based solutions are also applicable. The puncture of the abdomen is performed with a needle of small diameter on the median abdominal line, 0.5–1 cm below the umbilicus, perpendicular to the muscular layer. Following complete induction of anesthesia, the animal is placed ventral side up. Then the abdominal skin is shaved with electric clippers and after skin disinfection, a 1.5 cm midline incision is made at the median part of the abdomen. In the peritoneal implantation model, the capsule previously prepared is inserted into the right lower quadrant of the pelvic cavity. Animals recover quickly from anesthesia, after which they should be housed individually on wire supports. The intraperitoneal injection is widely used because of the swiftness and the easiness of the procedure. A visceral puncture (liver, stomach, caecum, colon, bladder) during the inoculation is the most frequent complication of this technique.
Staged abdominal repair (STAR) is a newly developed operative approach for the treatment of diffuse peritonitis. It demands a commitment at the first laparotomy for multiple relaparotomies scheduled at 24-h intervals. STAR reverses the patho-physiological impact of increased intra-abdominal pressure on pulmonary, renal, cardiovascular, and liver function and peritoneal blood flow. If required, prosthetic devices may be used to bridge any fascial gap and to accommodate the edematous peri-toneum and distended bowels. This minimizes fistula formation and deters abdominal fascial retraction, while permitting definitive abdominal fascial closure without evis-ceration and hernia formation. Since prospective controlled studies are difficult to perform and are therefore not available, we provide another model to test improvement in outcome following STAR. We stratified 95 patients treated by STAR according to the APACHE-II score and compared this series with 260 patients with infra-abdominal infections treated by conventional operative management (NON-STAR) and entered into a prospective multicenter observation study. Pearson chi-square analysis revealed no significant difference (P = 0.624) between mortality of STAR (24.2%) and NON-STAR (21.8%). The Mann-Whitney U-Test, however, showed a significant difference (P < 0.001) between the APACHE-II scores of STAR and NON-STAR, indicating that there might be a difference in mortality when comparing patients at equal mortality risk. To adjust for the significant differences in prognostic factors, we used a logistic model with APACHE-II scores as dependent variables and introduced a therapeutic categorical variable pair (STAR and NON-STAR) to examine the difference of their respective contribution to the event rate. A significant difference in the mortality was confirmed in favor of STAR (P = 0.0179), and the logistic equation is given by [Log p/l-p =-4.14 + (0.193* APACHE-II) + (0.4121 * OPERATION)], where OPERATION is +1 for NON-STAR patients and-1 for STAR patients. We conclude that STAR is superior to conventional operative therapy for advanced suppurative peritonitis.
Correspondence to: Dietmar H. Wittmann, at www.openabdomen.org
Objectives:
To assess the clinical significance of present scoring systems for prognosis and treatment in patients with secondary bacterial peritonitis and to define risk factors for patient survival and outcome not included in the scores. A secondary objective was to review our therapeutic regimens and the need for reoperation with regard to outcome.
Design:
Prospective observational study.
Setting:
University hospital, secondary referral center.
Patients:
From 1992 to 1995, 92 patients with secondary peritonitis were examined at the University Surgical Clinic, Vienna, Austria. The population as a whole consisted of 56 men and 36 women with an average age of 56±19 years. Forty-four percent of patients had postoperative peritonitis.
Outcome Measures:
Mortality, multiple organ system failure (MOSF), relaparotomy.
Results:
The mortality rate in patients with an APACHE II (Adult Physiology and Chronic Health Evaualtion) score of less than 15 was 4.8%, while mortality rose to 46.7% in those with a score of 15 or higher (P=.001). The average total mortality rate was 18.5%. The prognosis for patients without organ failure or with failure of one organ system was excellent (mortality rate, 0%); quadruple organ failure, however, had a mortality rate of 90%. Initial thrombocytopenia (<60×109/L), four-quadrant peritonitis, and diabetes mellitus were associated with significantly higher mortality. Leukopenia (white blood cells, <6×109/L) and inappropriate antibiotic therapy as determined by the antibiogram were mildly significant for higher mortality. The need for relaparotomy resulted in substantially higher mortality (P<.001). The impossibility of definitive operative resolution of the intra-abdominal pathologic findings at initial operation had no significant effect on mortality, possibly because planned reoperations were always carried out in those cases. For patients with definitive resolution at initial operation, it was possible to reduce the traditionally high mortality rate associated with relaparotomy on demand by making the decision for reexploration promptly, within the first 48 hours. Nevertheless, the 52.4% mortality rate observed in those cases was still much higher than the 33% found in patients who were not free of disease after the initial operation.
Conclusions:
The prognosis in peritonitis is decisively influenced by the health status of the patient at the beginning of treatment and by any concomitant risk factors. As a result, a fairly accurate prediction of the outcome of the disease can initially be made on the basis of the APACHE II score and the MOSF score according to Goris. However, the certainty that severely ill patients with high scores often die has little clinical relevance, since it does not provide any therapeutic alternatives to the attending physician. The decision to perform a relaparotomy must be made as soon as possible, at least before MOSF emerges. Already existing MOSF will lead to the "point of no return."(Arch Surg. 1996;131:180-186)
Objective:
To determine the effect of reoperation for severe abdominal sepsis on the course of proinflammatory mediators and hemodynamic factors.
Design:
Inception cohort.
Setting:
A university hospital and a secondary care hospital.
Patients and Methods:
Fifteen patients suffering from severe peritonitis due to intestinal perforation or infected necrotizing pancreatitis were studied following 19 subsequent operations. Plasma samples were obtained immediately before and after reoperation, as well as at 1, 3, 6, 12, and 24 hours after operation to determine endotoxin, tumor necrosis factor α, and interleukin-6 levels. Clinical factors and therapeutic support were recorded at the corresponding times.
Main Outcome Measures:
Postoperative hemodynamic instability as defined by changes of the mean arterial pressure, pulmonary capillary wedge pressure, and vasopressor support. Courses of proinflammatory mediators were correlated to the hemodynamic findings.
Results:
Mean arterial pressure decreased from 94 mm Hg postoperatively to 80 mm Hg at 3 hours (P=.006) and 81 mm Hg at 6 hours postoperatively (P=.005). Pulmonary capillary wedge pressure dropped from 14 mm Hg postoperatively to 12 mm Hg at 1 hour (P=.05). Vasopressor support significantly increased from 1 to 6 hours postoperatively (P=.02). Neither endotoxin nor tumor necrosis factor α levels showed significant changes in the postoperative course. Interleukin-6 levels continously increased from 586 pg/mL preoperatively to 910 pg/mL at 1 hour (P=.02) and 931 pg/mL at 3 hours postoperatively (P=.04). Overall interleukin-6 levels (R=−0.38, P=.003) and especially early postoperative interleukin-6 levels inversely correlated with postoperative mean arterial pressure.
Conclusions:
Reoperation for abdominal sepsis frequently causes substantial hypotension, and is, thus, potentially harmful to the patient. Reoperative trauma may induce an early postoperative increase in interleukin-6 levels. Because this increase occurs before the development of hypotension, a relationship between the kinetics of this cytokine and the observed hemodynamic instability may be present.Arch Surg. 1997;132:250-255
La utilización de una nueva alternativa terapéutica en pacientes afectos de carcinomatosis peritoneal mediante la aplicación de cirugía citorreductora radical oncológica, junto con la administración de quimioterapia intraperitoneal perioperatoria, supone un nuevo reto para los equipos multidisciplinarios que están al cuidado de estos pacientes, por cuanto su evolución postoperatoria y requerimientos de cuidados además de ser distintos de los de los pacientes convencionales, no están totalmente definidos ni protocolizados. El objetivo del presente trabajo es exponer nuestra experiencia con la aplicación del abdomen abierto en vacío, como técnica de cierre abdominal diferido, en el tratamiento de las complicaciones aparecidas en los pacientes sometidos a esta nueva triple terapia combinada.
Pour déterminer les principaux signes cliniques, biologiques et radiologiques chez des malades ayant un foyer infectieux intraabdominal après chirurgie digestive et la place qu'il reste aux réinterventions de principe, sont analysées ici les observations portant sur 79 malades traités en réanimation, depuis 1982. Il s'agissait de malades opérés d'une résection œsophagienne (n = 38), hépatique ou biliaire (n = 12), d'une chirurgie pancréatique (n = 17) et d'une résection colique (n = 12). Un foyer infectieux intraabdominal postopératoire a été découvert chez 75 malades. Il s'agissait de fistules œsophagiennes intrathoraciques ou intraabdominales (n = 31), d'abcès et fistules pancréatiques (n = 17), d'abcès péri ou intrahépatiques (n = 11), de fistules coliques (n = 12) et de cholécystites alithiasiques (n = 4). Il a été possible de distinguer deux groupes de malades selon l'intensité de la symptomatologie. Dans le premier groupe comprenant 12 malades, le syndrome infectieux est précoce et grave avec des hémocultures positives dans 60 % des cas. Ces signes sont présents dans les trois premiers jours postopératoires et les malades sont réopérés sans que les examens complémentaires participent à cette décision. Dans le second groupe comprenant 67 malades, la symptomatologie est plus fruste et c'est l'examen tomodensitométrique qui permet de retrouver dans 90 % des cas un foyer infectieux. Un abcès est ponctionné et drainé par voie percutanée avec succès chez 20 de ces malades. Chez six malades sans foyer décelable à l'examen tomodensitométrique, une réintervention de principe retrouve deux abcès, et cinq malades décèdent.
Enterococcus
,
Candida
,
Staphylococcus epidermidis
, and
Enterobacter
. Infectious foci were rarely amenable to percutaneous drainage and were found to be poorly localized at laparotomy. Recurrent, or tertiary, peritonitis is a common complication of intraabdominal infection in patients admitted to an ICU. It differs from uncomplicated secondary peritonitis in its microbial flora and lack of response to appropriate surgical and antibiotic therapy. Like nosocomial pneumonia in the critically ill patient, the syndrome appears to be more a reflection than a cause of adverse outcome.
Information on the species causing Candida peritonitis, their in vitro susceptibility, antifungal strategies in this setting and patient outcome is still scarce. AmarCand was a prospective, non-interventional study in 271 adult intensive-care unit (ICU) patients with proven invasive Candida infection who received systemic antifungal therapy (France, 2005-2006). Of these ICU patients, 93 (median age 65 years, simplified acute physiology score II 52) had Candida peritonitis, including 73 nosocomial peritonitis, 53 concomitant bacterial peritoneal infections and 26 candidaemias. Candida species were C. albicans (n = 63/108 isolates, 58%), C. glabrata (n = 22, 20%), C. krusei (n = 9), C. kefyr (n = 5), C. parapsilosis (n = 3), C. tropicalis (n = 3), C. ciferii (n = 2) and C. lusitaniae (n = 1). Of tested isolates, 28% were fluconazole-resistant or susceptible dose-dependent (C. albicans 3/32, C. glabrata 9/14, C. krusei 4/4). Empiric antifungal treatment was started 1 day (median) after peritonitis diagnosis, with fluconazole (n = 2 patients), caspofungin (n = 12), voriconazole (n = 3), amphotericin B (n = 2), or a combination (n = 4). Following susceptibility testing, empiric antifungal treatment was judged inadequate in 9/45 (20%) patients and modified in 30 patients (fluconazole was replaced by caspofungin (n = 14) or voriconazole (n = 4)). Mortality in ICU was 38% (35/93) and was not influenced by type of Candida species, fluconazole susceptibility, time to treatment, candidaemia, nosocomial acquisition, or concomitant bacterial infection. No specific factors for death were identified. In summary, a high proportion of fluconazole-resistant or susceptible dose-dependent strains was cultured. These results confirm the high mortality rates of Candida peritonitis and plead for additional investigation in this population. Antifungal treatment for severe cases of Candida peritonitis in ICU patients remains the standard care.
Unlabelled:
Acute abdominal pain may be caused by a myriad of diagnoses, including acute appendicitis, diverticulitis, and cholecystitis. Imaging plays an important role in the treatment management of patients because clinical evaluation results can be inaccurate. Performing computed tomography (CT) is most important because it facilitates an accurate and reproducible diagnosis in urgent conditions. Also, CT findings have been demonstrated to have a marked effect on the management of acute abdominal pain. The cost-effectiveness of CT in the setting of acute appendicitis was studied, and CT proved to be cost-effective. CT can therefore be considered the primary technique for the diagnosis of acute abdominal pain, except in patients clinically suspected of having acute cholecystitis. In these patients, ultrasonography (US) is the primary imaging technique of choice. When costs and ionizing radiation exposure are primary concerns, a possible strategy is to perform US as the initial technique in all patients with acute abdominal pain, with CT performed in all cases of nondiagnostic US. The use of conventional radiography has been surpassed; this examination has only a possible role in the setting of bowel obstruction. However, CT is more accurate and more informative in this setting as well. In cases of bowel perforation, CT is the most sensitive technique for depicting free intraperitoneal air and is valuable for determining the cause of the perforation. Imaging is less useful in cases of bowel ischemia, although some CT signs are highly specific. Magnetic resonance (MR) imaging is a promising alternative to CT in the evaluation of acute abdominal pain and does not involve the use of ionizing radiation exposure. However, data on the use of MR imaging for this indication are still sparse.
Supplemental material:
http://radiology.rsna.org/content/253/1/31/suppl/DC1.
Despite improvements in treatment, secondary peritonitis still is associated with high morbidity and mortality rates. Better knowledge of real-life clinical practice might improve management.
Prospective, observational study (January-June 2005) of 841 patients with non-postoperative secondary peritonitis.
Peritonitis originated in the colon (32% of patients), appendix (31%), stomach/duodenum (18%), small bowel (13%), or biliary tract (6%). Most patients (78%) presented with generalized peritonitis and 26% with severe peritonitis (Simplified Acute Physiology Score [SAPS] II score>38). Among the 841 patients, 27.3% underwent laparoscopy alone; 11% underwent repeat surgery, percutaneous drainage, or both. A SAPS II score>38 and the presence of Enterococcus spp. were predictive of abdominal and non-surgical infections (odds ratio [OR]=1.84; p=0.013 and OR=2.93; p<0.0001, respectively). A SAPS II score>38 also was predictive of death (OR=10.5; p<0.0001). The overall mortality rate was high (15%). Patients receiving inappropriate initial antimicrobial therapy had significantly higher morbidity and mortality rates than patients receiving appropriate therapy (44 vs. 30%; p=0.004 and 23% vs. 14%; p=0.015, respectively). The SAPS II score and rates of severe peritonitis, morbidity, and mortality were significantly lower in patients with appendiceal peritonitis.
Patients with non-postoperative peritonitis should be considered high risk and should receive appropriate initial therapy. The presence of Enterococcus spp. in peritoneal cultures significantly increased morbidity but not the mortality rate. Appendiceal peritonitis that was less severe and had a better prognosis than peritonitis originating in other sites should be considered a special case in future studies.
The use of a new therapeutic alternative involving cytoreductive surgery with perioperative intraperitoneal chemotherapy in the treatment of patients suffering from peritoneal carcinomatosis represents a new challenge for the multidisciplinary teams caring for these patients. Their post-operative progress and care needs, apart from differing from those of conventional patients, have not yet been completely defined or protocolised. In this presentation we explain the special characteristics of these patients compared to the usual surgical patients, the possible physiopathological mechanisms which may give rise to the different types of complications, the circumstances when a temporary abdominal closure is necessary, the ideal conditions required for an optimal technique, and finally our experience with the open vacuum abdomen technique in the treatment of the complications that appear in patients treated by this new triple combined therapy.
Based on our personal experience in the treatment of 110 cytoreductions carried out between February 1997 and February 2007 on 71 patients suffering from peritoneal carcinomatosis of various origins. Of the 71 patients, 50 (70%) suffered some kind of complication during their postoperative evolution, 28 of them requiring re-operation for a Grade III-IV postoperative complication. The abdominal situation made a temporary closure desirable in 17 patients, having applied an open vacuum abdomen technique on every occasion. We study this group of patients according their original type of tumour and stage of the disease at the cytoreductive procedure, peritonectomies and visceral resections required, type of postoperative complications, treatment applied and evolution.
A total of 52 open vacuum abdomen procedures were required (median, 2.8 per patient; range, 1-10) before the abdominal complication could be completely kept under control in these 17 patients. Only 2 postoperative intestinal fistulas were directly related to this technique, and a primary closure of the whole abdominal wall was possible in 11 of these patients (66%). All but one of them left the hospital alive and well.
As a consequence of this experience, in our opinion, the open vacuum abdomen is the ideal election technique to be employed in any temporary closure of the abdominal cavity for whatever reason it is required, including the worst possible surgical scenario, as we have demonstrated in the treatment of surgical complications after cytoreductive procedures and intraperitoneal chemohyperthermia.
• Intra-abdominal sepsis that involves multiple aerobic and anaerobic bacteria derived from the colonic flora was studied in Wistar rats to determine the relative roles of various microbial species. The rats challenged with pooled colonic contents showed a biphasic disease. Initially, there was acute peritonitis, Escherichia coli bacteremia, and high mortality. In rats that survived this acute peritonitis stage, intra-abdominal abscesses developed, and anaerobic bacteria were the preponderant organisms. Subsequent experiments showed that antibiotics directed against coliforms prevented mortality, whereas agents active against anaerobes reduced the incidence of abscesses. Challenges with Escherichia coli alone produced bacteremia and death, whereas pure cultures of Bacteroides fragilis caused intra-abdominal abscesses. These observations suggest that both coliforms and anaerobes are important pathogens in intra-abdominal sepsis, although the different types of microbes appear to play distinctive roles in the sequence of pathological events.
(Arch Surg 113:853-857, 1978)
The production of TNF-alpha, IL-1, and IL-6 was measured in mice after bolus i.v. Escherichia coli O111 LPS injections and during bacteremia induced either by bolus i.v. or by i.p. challenges of live E. coli O111. High but transient TNF-alpha peaks were observed after bolus i.v. LPS or bacterial challenges. In contrast, the levels during lethal peritonitis increased progressively to values 50- to 100-fold lower than the peak values observed after i.v. injections, and remained sustained until death. Whereas after i.v. challenge with 1000 LD50 of LPS, anti-TNF-alpha antibody fully protected mice from death and reduced serum IL-1 and IL-6 levels, anti-TNF-alpha antibody did not improve the survival of mice nor reduced serum IL-1 and IL-6 levels after i.p. bacterial challenge. In contrast to anti-TNF-alpha antibodies, anti-LPS antibodies were protective in the peritonitis model. Protection was accompanied by a striking reduction of bacterial numbers and of TNF-alpha, IL-1, and IL-6 levels in the serum, but the levels of these cytokines were only marginally affected in the peritoneal lavage fluid. This latter observation demonstrates that the local peritoneal cytokines did not diffuse readily into the circulation, thus suggesting that at least part of the circulating cytokines are produced systemically. In conclusion, the striking differences between cytokine profiles as well as the divergent efficacy of anti-TNF-alpha antibody after i.v. bolus and after i.p. challenges suggest that TNF-alpha may not be as important in the pathogenesis of lethal peritonitis than after lethal acute bacteremia.
The charts of 480 patients with secondary bacterial peritonitis were reviewed. The antibiotics used were compared with the culture and sensitivity data obtained at surgery, and the outcomes of patients were evaluated. Patients treated with a single broad-spectrum antibiotic had a better outcome than patients treated with multiple drug treatment. Inadequate empiric antibiotic treatment was associated with poorer outcome than any other type of treatment. The outcome of this inadequate treatment group could not be improved by any antibiotic response to culture and sensitivity information after operation. Those patients treated with antibiotic coverage for anticipated organisms and having no cultures taken did as well as patients having cultures taken. Surgeons typically ignore culture data after operation, and only 8.8% of patients in this study had an appropriate change in antibiotic treatment after operation. A benefit from obtaining operative cultures could not be identified.
We designed a multicenter study to compare tobramycin/clindamycin to imipenem/cilastatin for intra-abdominal infections. We included the Acute Physiology and Chronic Health Evaluation (APACHE II) index of severity and excluded patients without established infection. Two hundred ninety patients were enrolled, of whom 162 were evaluable. Using logistic regression to analyze both outcome at the abdominal site of infection and outcome as mortality, we found a significant correlation for both with APACHE II score (p less than 0.0001 for both). Next we analyzed the residual effect of treatment assignment and found a significant improvement in outcome for imipenem/cilastatin-treated patients (p = 0.043). The differences in outcome were explained by a higher failure rate for patients with gram-negative organisms for tobramycin/clindamycin-treated patients (p = 0.018). This was reflected in a significantly higher incidence of fasciitis requiring reoperation and prosthetic fascial replacement. Maximum peak tobramycin levels were analyzed for 63 tobramycin/clindamycin patients harboring gram-negative organisms. For failures the maximum peak was 6.4 +/- 1.9 micrograms/mL, and time to maximum peak was 4.6 +/- 5.2 days. For successes the maximum peak was 6.1 +/- 1.7 micrograms/mL, occurring at 3.8 +/- 2.6 days. This study supports inclusion of severity scoring in statistical analyses of outcome results and supports the notion that imipenem/cilastatin therapy improves outcome at the intra-abdominal site of infection as compared to a conventionally prescribed amino-glycoside-based regimen.
Substances that may influence the course and outcome of intra-abdominal sepsis were investigated in an experimental model of Escherichia coli peritonitis in rats. All rats received an intraperitoneal injection of E. coli. In the first set of experiments, substances commonly contaminating the abdominal cavity after trauma were intraperitoneally injected, and the following mortality rates were found: saline solution (controls) 27%, hemoglobin solution 80% (p less than 0.01), whole blood 20% (p greater than 0.05), whole blood together with bile 93% (p less than 0.001) and bile 87% (p less than 0.01). In the second set of experiments, intravenous injection of commonly used solutions gave mortality rates of 20% (controls) for saline solution, 80% for dextran (p less than 0.01) and 47% for Intralipid (p greater than 0.05). E. coli peritonitis in rats thus was aggravated by intraperitoneal hemoglobin, bile or whole blood plus bile, and also by intravenous dextran.
A prospective audit of the frequency of infective complications after all abdominal operations was carried out between January 1977 and December 1986. A total of 3100 abdominal procedures (2041 elective; 1059 emergency) were performed in 3056 patients. There were 50 (1.6 per cent) in-hospital and 66 (2.1 per cent) late wound infections (overall 3.7 per cent). Fifty-four (1.8 per cent) patients developed postoperative intraperitoneal sepsis. Ninety-eight patients died (overall mortality 3.2 per cent) and intraperitoneal sepsis was a related factor in twelve (0.4 per cent). Wound infection, peritoneal sepsis and mortality were related to the degree of operative contamination and to reoperation. The results support the traditional, although sometimes inadequately stressed, teaching that technique is an important factor in preventing infection. Infection is also reduced by peroperative antibiotic lavage. The limited value and the potential difficulties of the unstructured introduction of computerized audit should be recognized.
During the period 1979-84, 30 abdominal re-explorations were performed for postoperative intra-abdominal sepsis and single or multiple organ failure in jaundiced patients. Postoperative sepsis was caused by intra-abdominal abscess in 16 cases (53 per cent), by suture line leakage in 9 cases (30 per cent) and by technical error in 5 cases (17 per cent). Abscesses occurred most commonly in the subphrenic space (6 cases), in the subhepatic space (6 cases) and in the lesser sac (5 cases). Sepsis was associated with single organ failure in 20 cases and with multiple organ failure in 10 cases. The overall mortality rate was 50 per cent (15/30). Factors that were statistically associated with fatal outcome were: serum bilirubin greater than 100 mumol/l (P less than 0.008), positive blood culture (P less than 0.013), malignant disease (P less than 0.02), multiple organ failure (P less than 0.02) and age greater than 60 years (P less than 0.031). Mortality rose with the number of failed organs. Autopsy revealed continuing sepsis in 12 of the 15 fatal cases. Because mortality was high in spite of adequate operative drainage at relaparotomy, it is concluded that earlier definitive diagnostics are needed to lower the mortality rate.
A prospective study was performed on 635 patients with appendicitis operated on by 7 trainees and 119 patients operated on by 6 senior surgeons with more than 8 years of surgical experience. In patients with normal appendices, postoperative sepsis was extremely low. For early and late appendicitis, the infection rates of the trainees decreased as experiences accumulated, but they were still higher than that of the senior surgeons. The difference in infection rates in acute appendicitis did not reach statistical significance between any of the training stages and between the various stages and the rate of the senior surgeons. The differences in infection rates in late appendicitis between stage 1 and stage 3 was significant, as was the difference in infection rates between stage 1 and the infection rate of the senior surgeons. Therefore, we have concluded that overall, the limited experience of trainees is related to the rate of postoperative sepsis in late appendicitis, although the infection rates of individual trainees vary a lot.
The mortality rate of severe intra-abdominal infections is still very high. The open management of the abdomen is a method of treatment which has gained popularity over the past few years. Its advantages include a better drainage of the peritoneal cavity, a greater protection of the parietes, an improved perfusion of the abdominal viscera and a decrease in postoperative pulmonary complications. It is indicated in patients with severe intra-abdominal sepsis, especially when multiple re-explorations of the abdomen are likely. A variety of techniques, including the use of Marlex mesh have been devised to contend with possible complications: spontaneous fistulas, exogenous bacterial contamination, evisceration and massive fluid losses. The open method of management has not made the treatment of septic abdomen much easier; it requires intensive care support and repeated assessment of the peritoneal cavity. The closure of the abdomen is a problem which must be addressed when the sepsis has subsided. The value of this technique is still difficult to assess in the absence of controlled randomized trials.
A total of 113 patients having elective resection of the alimentary tract were studied prospectively to examine the relationship of pre-operative clinical and nutritional assessment to the development of major postoperative complications. In addition, the operating surgeon made a risk assessment on a linear analogue scale before and immediately after operation. Major complications developed in 28 patients (25 per cent). Age, weight loss and relative weight did not select high risk patients, but patients with a serum albumin of 29 g/l developed significantly more complications than those with higher levels (60 versus 22 per cent, P less than 0.05). Clinical assessment also selected some high risk patients but patients selected by the surgeon's pre-operative assessment did not develop significantly more complications than those not selected (38 versus 21 per cent). However, the surgeon's postoperative assessment did select patients at significantly increased risk, especially when compared with his pre-operative assessment. Of 38 patients who were selected pre-operatively as high risk or who increased their risk ranking postoperatively, 20 (53 per cent) developed complications, as opposed to only 6 of 65 patients (9 per cent) who were low risk or decreased their risk ranking (P less than 0.001). The surgeons changed their ranking postoperatively in 44 patients and in 36 (82 per cent) the reason given was the technical ease or difficulty of the procedure. Using receiver-operating characteristic curves, immediate postoperative assessment was superior to any pre-operative method of selecting high risk patients. Of 15 patients with normal serum albumin levels whose risk ranking increased postoperatively 6 (40 per cent) developed complications while none of the 7 patients with low serum albumin (high risk) who decreased their risk ranking developed complications. It is concluded that operative performance is the main factor in the development of postoperative complications and should be assessed in future studies of outcome.
The charts of 25 patients who died in the intensive care unit of persistent peritonitis after abdominal operations were reviewed to determine the microbial flora and the efficacy of antibiotic treatment. All patients had undergone two or more surgical procedures for abdominal sepsis and 23 had at least three-system organ failure. The most common organisms cultured were: Staphylococcus epidermidis, 24 cultures from 16 patients, Candida albicans, 19 cultures from 10 patients, Pseudomonas aeruginosa, 16 cultures from 12 patients, Enterobacter, 16 cultures from 8 patients and enterococcus, 14 cultures from 8 patients. The classic isolates, Escherichia coli (11 cultures from six patients) and Bacteroides fragilis (4 cultures from three patients) were found infrequently. To determine the adequacy of antimicrobial therapy for this "new" flora, we examined the ability of appropriate agents to eradicate the micro-organism upon subsequent culture. Candida sp. were eradicated in 54% (6 of 11) of the assessable cases, while enterococcus and S. epidermidis were cleared in only 25% and 28% respectively. The spectrum of intra-abdominal organisms cultured from critically ill surgical patients in the intensive care unit differs from that seen in those with acute peritonitis. Despite administration of appropriate antimicrobial agents, these organisms tend to persist, probably reflecting impaired host defences with multiple-system organ failure rather than antimicrobial failure.
Surgical infections are almost always polymicrobial, yet the critical importance of bacterial mixtures in these infections
has received relatively little attention. The convincing data on the prevalence of mixed infections in surgery are reviewed.
Both clinical and experimental evidence indicate that true synergy between certain aerobes and anaerobes may exist. Of the
possible mechanisms of synergy, the most important seems to be the ability of anaerobes, their metabolic products, or their
capsules to inhibit phagocytosis of aerobes by leukocytes. Other mechanisms of importance in special microbial combinations
include provision of essential nutrients such as vitamin K, succinate, and various growth factors by one microbe to the other;
alteration of local environment, including reduction of the oxygen tension and lowering of redox potential; and the provision
of substances toxic to the host that permit species of bacteria to flourish concurrently. Further study of these interactions
will shed light on the causes and correction of treatment failure.
• We measured the rate of lethality and abscess formation in rats that underwent intraperitoneal implantation of fibrin clots contaminated with either Escherichia coli or Bacteroides fragilis alone or in combination, to determine whether the two organisms together would produce a synergistic infection. Ten-day mortality produced by 109 colony-forming units (CFU) of E coli was 33.3%. Encapsulated B fragilis led to 3.3% mortality. Escherichia coli (5× 108 CFU) plus B fragilis (5×108 CFU) led to a sharp increase both in the rate and final ten-day mortality (80.0%). Eighty percent of the rats that received E coli (109 CFU within fibrin clots) had abscesses determined on the basis of grossly purulent material. All animals that received B fragilis and survived ten days contained abscesses. Synergy between E coli and B fragilis was noted to occur only when 5 × 108 CFU of each organism was present within the fibrin clot. Lower numbers did not produce significant synergy compared with controls that received either E coli or B fragilis. Quantitation of the number of organisms present at 24 hours within contaminated fibrin clots demonstrated a similar amount of growth of both organisms, either when added alone or in combination as copathogens.
(Arch Surg 1984;119:139-144)
In a 2-year period (1981-1983), 87 abdominal re-explorations (1.6% of total laparotomies) were performed on 77 patients for sepsis in five Downstate hospitals. Fifty-one patients were re-explored solely on clinical grounds, 21 on clinical plus radiographic criteria, four solely on radiographic grounds, and 11 for multiple organ failure. The overall mortality rate was 43%. As expected, the most common laparotomy finding was intra-abdominal abscess (47); other findings included anastomotic leak (14), necrotic bowel (10), evidence of technical error (five), and acalculous cholecystitis (two). The most common clinical findings were localized tenderness, fever, and absent bowel sounds (85%). Fifty-four special studies were performed with an overall accuracy rate of 76%. CAT scans and contrast radiographs were most accurate (92% and 81%) while sonography and gallium scans were less useful (59% and 60%). Seven patients had negative laparotomies. While all were distended and six were febrile, only one patient had focal tenderness. In the 11 patients explored solely for multiple organ failure, six patients had drainable pus despite negative radiographic studies, and two survived. The other five patients had negative laparotomies, and all died. Factors correlated with mortality were age over 50, peritonitis at the primary operation, and multiple organ failure. The approach to these seriously ill patients should be governed by a high index of suspicion. Clinical findings are at least as reliable as sophisticated radiographic modalities of which CAT scan appears to be the most accurate. Re-exploration for multiple organ failure alone will yield a significant group of patients with drainable septic foci and some survivors; thus, exploration for this indication appears to be defensible.
Generalized peritonitis was assessed in 176 patients, 67 (38%) of whom died. Cases were divided into causative groups: (1) appendicitis and perforated duodenal ulcer, (2) intraperitoneal origin other than appendix or duodenum, and (3) postoperative peritonitis. Mortalities were 10%, 50%, and 60%, respectively. Postoperative peritonitis was characterized by lack of influence of age on outcome, late operation, and more frequent organ failure. Delayed surgery carried a worse prognosis. Organ failure was a risk factor with 76% mortality, and was associated with late operation. Early surgery in organ failure improved survival. More sensitive indicators of early organ dysfunction might improve survival.
A review of 100 consecutive patients with intraabdominal abscesses treated since the advent of the CAT scanner has been presented. Each patient was analyzed with regard to etiology, bacteriology, sensitivity of preoperative diagnostic studies, method of drainage, mortality, and morbidity. Abscesses developed in 71 percent of these patients as a result of spontaneous intraabdominal disease, and in 29 percent as a complication of operation or procedures. Sixty percent of cultures grew anaerobic organisms. The sensitivity of CAT scanning (92 percent) was significantly better than that of ultrasonography (77 percent) or gallium scanning (75 percent). When ultrasound was used in conjunction with CAT scanning there was no improvement in sensitivity. Patients who had CAT scans were more likely to have extraserous drainage (p < 0.05) than those who did not. Ultrasound was indicated in selected clinical situations. The overall mortality rate of 12 percent was significantly better (p < 0.05) than the mortality rate of 28 percent in the previous 5 year period. Organ failure, which carries a high mortality in septic patients, was observed in only 13 percent of our patients who had CAT scans. We attribute the decrease in mortality to earlier diagnosis and drainage, wider use of extraserous drainage due to utilization of new imaging techniques, and to the use of antibiotics effective against both aerobic and anaerobic organisms.
• The overall mortality in 77 cases of intra-abdominal infection (IAI) was 39%. A striking correlation was observed between delay in definitive medical or surgical treatment, the number of medical and surgical complications, and mortality. Only one of 29 patients who showed a rapid clinical response to appropriate antibiotic treatment and/or an exploratory operation died, compared with 29 of 48 who did not, justifying a vigorous diagnostic approach with repeated exploratory surgery when necessary. Results of abdominal ultrasound and gallium scanning altered management in a meaningful fashion far less frequently than might be inferred from earlier reports. Factors contributing to delays in instituting definitive therapy included failure to recognize the presence of IAI, prolonged observation in the absence of noticeable response to medical therapy, the desire for confirmation by ancillary studies, and the argument that the patient was "too sick" to undergo surgery.
(Arch Surg 1982;117:328-333)
The role of enterococcus in intraabdominal infection is controversial. This study examines the contribution of enterococcus to adverse outcome in a large intraabdominal infection trial.
A randomized prospective double-blind trial was performed to compare two different antimicrobial regimens in combination with surgical or percutaneous drainage in the treatment of complicated intraabdominal infections. A total of 330 valid patients was enrolled from 22 centers in North America.
In 330 valid patients, 71 had enterococcus isolated from the initial drainage of an intraabdominal focus of infection. This finding was associated with a significantly higher treatment failure rate than that of patients without enterococcus (28% versus 14%, p < 0.01). In addition, only Acute Physiology and Chronic Health Evaluation II score and presence of enterococcus were significant independent predictors of treatment failure when stepwise logistic regression was performed (p < 0.01 and < 0.03). Risk factors for the presence of enterococcus include age, Acute Physiology and Chronic Health Evaluation II, preinfection hospital length of stay, postoperative infections, and anatomic source of infection. There was no difference between the clinical trial treatment regimens with regard to overall failure, failure associated with enterococcus, or frequency of enterococcal isolation.
This study is the first to report enterococcus as a predictor of treatment failure in complicated intraabdominal infections. This trial also identifies several significant risk factors for the presence of enterococcus in such infections.