Does noncomplicated acute appendicitis cause bacterial translocation?

Laparoscopic Appendectomy Combined with an "Antimicrobial-Free" Strategy for Acute Uncomplicated Appendicitis

Objective: To explore the efficacy and safety of enhanced recovery protocol (ERP) combined with laparoscopic appendectomy (LA) in the treatment of acute uncomplicated appendicitis (AUA) without antibiotics. Methods: In this study, a total of 160 patients with AUA who underwent LA between January 2018 and December 2021 were included and divided into the antibiotic group (n = 80) or the no-antibiotic group (n = 80). The patients in the antibiotic group received the ERP combined with antimicrobials during the perioperative period, while those in the no-antibiotic group only received the ERP during the perioperative period. The clinical data of these patients were collected to compare the inflammation level and stress state before and after surgery. In addition, the incidence of postoperative complications and the recovery speed of the patients were compared between groups. Results: There were no significant differences in the inflammation level and stress state before or after surgery, the incidence of postoperative complications or the recovery speed between the antibiotic group and the no-antibiotic group (P > .05). Conclusion: The use of ERP combined with LA as an antimicrobial-free treatment scheme in the perioperative period was found to be safe and effective for patients with AUA. Therefore, this approach is clinically valuable.

Is Routine Intra-operative Gram Stain, Culture, and Sensitivity during an Appendectomy is Effective in Decreasing the Rate of Post-operative Infective Complications?

BACKGROUND: Organisms blamed in acute appendicitis are right predictable and very susceptible to a wide range of broad-spectrum antibiotics. AIM: The aim of the study was to assess the clinical benefit of the routine intra-operative swab during an appendectomy in guiding antibiotic selection. METHODS: Four hundred and thirty patients underwent appendectomy halved into two groups, each 215. In Group 1, an intra-operative swab was routinely obtained for culture/sensitivity. The results of which were reviewed for helping direct antibiotic selection. No intra-operative swabs were obtained in Group 2. Both groups were given single-dose cefotaxime and metronidazole preoperatively intravenously at the time of induction of anesthesia. RESULTS: In swab group, 63/215 cultures (29.3%) revealed pathogens, while (70.7%) were negative or revealed isolated colonic commensals. Most cultures were negative or isolated colonic commensals. Fifty-two/63 cultures (82.54%) were sensitive to both cefotaxime and metronidazole, and only 11/63 (17.46%) reported resistant organisms to cefotaxime but not to metronidazole. Most pathogens were sensitive to empirical antibiotics. Twenty-two/215 patients (10.23%) developed infective complications, most (63.6%) had their cultures from the infected wound yielded different micro-organisms. Only 8/215 (3.72%) in the swab group needed a change in the empirical antibiotics for treating infective complications. In the non-swab group, 19/215 patients (8.83%) developed infective complications. Only 6/215 patients (2.8%) needed a change in the empirical antibiotics for treating infective complications. Collectively, only 14/430 patients (3.25%) required a change in the empirical antibiotics for treating infected wounds. CONCLUSIONS: Routine peritoneal swabs for culture/sensitivity during appendicectomy are of no clinical value. Such practice is considered a waste of laboratory resources and money. A single prophylactic dose of antibiotics has significant role in preventing surgical site infection.

Bacterial culture and antibiotic susceptibility in patients with acute appendicitis

PURPOSE

Essential treatment of acute appendicitis is surgical resection with the use of appropriate antibiotics. In order to effectively treat acute appendicitis, it is important to identify the microorganism of acute appendicitis and evaluate the effective antibiotics.

METHODS

A total of 694 patients who underwent appendectomy for acute appendicitis and had positive microbial result between 2006 and 2015 were recruited. For microbial assessment, luminal contents of the appendix were swabbed after appendectomy. In patients with periappendiceal abscess, the specimens were obtained from abscess fluid. The patient characteristics, operative data, use of antibiotics, the results of microbiology, and postoperative morbidities including surgical site infection (SSI) were retrospectively reviewed.

RESULTS

The mean age was 38.2 (± 19.8) years, and 422 patients (60.8%) were male. Most of the operations were performed by conventional laparoscopy (83.1%), followed by single-port laparoscopy (11.8%). The most common microorganism was Escherichia coli (64.6%), which was susceptible to amoxicillin/clavulanate, ciprofloxacin, most cephalosporins, piperacillin/tazobactam, and imipenem. The second most common microorganism was Pseudomonas aeruginosa (16.4%), which was resistant to amoxicillin/clavulanate and cefotaxime. The rate of postoperative morbidity was 8.6%, and the most common type was superficial SSI (6.2%), followed by ileus (1.2%), gastroenteritis (0.7%), and organ/space SSI (0.3%). P. aeruginosa (odds ratio = 2.128, 95% confidence interval 1.077-4.206, P = 0.030) was the only significant microorganism associated with SSI according to multivariate analysis adjusting for other clinical factors.

CONCLUSIONS

In perforated appendicitis, the use of empirical antibiotics seems to be safe. In some cases of Pseudomonas infection, adequate antibiotics should be considered.

The Influence of Carbon Dioxide Pneumoperitoneum on Systemic Inflammatory Response Syndrome and Bacterial Translocation in Patients With Bacterial Peritonitis Caused by Acute Appendicitis

OBJECTIVE

To explore the influence of carbon dioxide pneumoperitoneum (CDP) on system inflammatory response syndrome (SIRS) and bacterial translocation (BT) in patients with bacterial peritonitis (BP) caused by acute appendicitis (AA).

METHODS

Eighty-six consecutive subjects were randomly divided into the laparoscopy and laparotomy groups (n = 44 and n = 42, respectively). The levels of white blood cells (WBC), C-reactive protein (CRP), tumor necrosis factor α (TNF-α), and interleukin 6 (IL-6) of the 2 groups were tested preoperatively and at days 1, 2, and 4 after surgery. Blood and secretion culture was performed to verify whether septicemia or incision infection occurred, respectively. And the abdominal ultrasound or computed tomography scanning was used to diagnose peritoneal abscess for the suspected patients. The essential risk factors related to the aggravation of SIRS were analyzed through analysis of variance and binary logistic regression.

RESULTS

The postoperative blood levels of WBC, CRP, TNF-α, and IL-6 on day 4 in the laparoscopy group were significantly lower than those in the control group (all Ps < .05). The differences in incidence rates of septicemia and peritoneal abscess between the CDP and control groups were not statistically significant ( P > .05). Nevertheless, the incision infection rate in the laparoscopy group was apparently lower than that in the control group (4.55% vs 19.04%, P = .047). Analysis of variance and binary logistic regression showed that the non-pneumoperitoneum, pathological type of appendicitis, and multidrug resistant infections were the 3 major risk factors for SIRS (the P values were .001, .019, and .012, respectively).

CONCLUSION

It was found that CDP is safe for BP and could be a potential protective factor to mitigate BP effectively, indicating that the performance of laparoscopy operation under CDP is feasible to control SIRS; at the same time, CDP would not raise the incidence rate of BT.

A "shocking" appendicitis

We report a case of Klebsiella oxytoca sepsis as a complication of nonperforated appendicitis in an 11-year-old immunocompetent boy. Even if septicemia is not mentioned in major reviews as a complication of nonperforated appendicitis, several cases have occasionally been reported in adult patients in the literature. The pathogenesis of sepsis with nonperforated appendicitis is still not clear, but a mechanism of bacterial translocation has been taken into account to explain the spread of microorganisms from the intestinal lumen to the systemic blood stream. Clinicians should therefore be aware of this occurrence.

The diagnostic value of D-dimer, procalcitonin and CRP in acute appendicitis

BACKGROUND

The early diagnosis of acute abdomen is of great importance. To date, several inflammatory markers have been used for the diagnosis of acute abdominal conditions, including acute appendicitis. The aim of this study was to evaluate the diagnostic utility of D-dimer, Procalcitonin (PCT) and C-reactive protein (CRP) measurements in the acute appendicitis.

METHODS

This prospective study was conducted between March 1(st), 2010 and July 1(st), 2011. In this period, seventy-eight patients were operated with the diagnosis of acute appendicitis, and D-dimer, PCT and CRP levels of the patients were measured. The patients were grouped as phlegmonous appendicitis (Group 1), gangrenous appendicitis (Group 2), perforated appendicitis (Group 3) and negative appendectomy (Group 4) according to the surgical findings and histopathological results.

RESULTS

Of 78 patients, 54 (69.2 %) were male and 24 (30.8 %) were female, and the mean age was 25.4 ± 11.1 years (range, 18 to 69 years). 66 (84.6 %) patients had increased leukocyte count (white blood cell count). The PCT values were higher than the upper normal limit in 20 (25.6%) patients, followed by D-dimer in 22 (28.2 %) patients and CRP in 54 (69.2 %) patients. The diagnostic value of leukocyte count and CRP in acute appendicitis was higher than that of the other markers, whereas leukocyte count showed very low specificity. CRP values were higher in perforated appendicitis when compared with the phlegmonous appendicitis (p < 0.05). However, PCT and D-dimer showed lower diagnostic values (26% and 31%, respectively).

CONCLUSION

An increase in CRP levels alone is not sufficient to make the diagnosis of acute appendicitis. However, CRP levels may differentiate between phlegmonous appendicitis and perforated appendicitis. Due to their low sensitivity and diagnostic value, PCT and D-dimer are not better markers than CRP for the diagnosis of acute appendicitis.

Peritoneal fluid culture in appendicitis: review in changing times

Appendicectomy is one of the commoner operations with a lifetime risk as high as 12% or 23% in males or females, respectively. Since the 1940s intra-operative intra-peritoneal swabs have commonly been taken from the appendix site, the spectrum of infecting organisms and their antibiotic sensitivity may be gauged from the culture results. This approach remains common but in recent years, studies have claimed that intra-peritoneal swabs are unnecessary; however, they relied upon retrospective patient groups predating wider use of laparoscopic appendicectomy, increasing numbers of immunocompromised people at risk of appendicitis and the clinical/medicolegal significance of increasing risk of antibiotic-associated Clostridium difficile colitis. Therefore, a key-word literature research was done to identify relevant publications from 1930 to June 2009. Newer features relating to intra-peritoneal swabs in appendicectomy have been discussed against this background information for periabdominal appendicectomy with or without appendicular perforation, laparoscopic appendicectomy and appendicectomy in the growing numbers of immunocompromised patients. All studies questioning the use of intra-peritoneal swabs were open, non-randomised, and retrospective with incompletely matched control groups, non-standardised swab collection techniques, and consequently lacked power to inform surgical practice. They concluded that an appropriately powered randomised, blinded, prospective, controlled clinical trial is needed to test for absolute efficacy in the use of peritoneal swabs in patient management. Until controlled trial data becomes available, it may be wise to continue peritoneal swabs at least in high-risk patients to decrease clinical and medicolegal risk.

Acute appendicitis presenting with Klebsiella pneumoniae septicemia due to bacterial translocation

Bacterial translocation (BT) is defined as the passage of viable bacteria from the gastrointestinal tract, across the intestinal wall, to the mesenteric lymph nodes or other extranodal sites and bloodstream. It has been shown in both animal and human studies and has been implicated as a source of sepsis in susceptible patients. Herein, a rare case of acute appendicitis in a nonimmunocompromised patient who presented with manifestations of Klebsiella pneumoniae septicemia, is described. Translocation of Klebsiella pneumoniae through the compromised appendix mucosa leading in dissemination of the infection into the bloodstream was likely the main causative factor for the atypical and toxic presentation of acute appendicitis. Thorough clinical investigation ruled out other sources of infection. Emergency physicians should be aware that septicemia may be the dominant presentation of acute appendicitis, due to dissemination of the infection into the bloodstream, secondary to bacterial translocation.

A prospective bicenter study investigating the diagnostic value of procalcitonin in patients with acute appendicitis

BACKGROUND

Procalcitonin (PCT) is an established laboratory marker for disease severity in patients with infection and sepsis. In addition, PCT has been shown to be an effective marker for a limited number of localized infections. However, whether or not PCT has any diagnostic value for acute appendicitis, still remains unclear. The purpose of this prospective bicenter study was, therefore, to determine whether or not the PCT levels in the serum of patients with acute appendicitis have any diagnostic value.

METHODS

This prospective study included 103 patients who received an appendectomy, based on the clinical diagnosis of acute appendicitis, in a surgical department of an academic teaching hospital in Germany or in a county hospital in Spain. White blood cell count (WBC), C-reactive protein (CRP) and procalcitonin (PCT) values were determined preoperatively. All appendectomy specimens were sent for routine histopathological evaluation. Based on this information, the patients were assigned to 1 of 5 groups that reflected the severity of the appendicitis.

RESULTS

Of the 103 patients who were included in the study, 98 had appendicitis. Fourteen (14.3%) showed an increase in PCT values. Of those 14, 4 had a serum PCT >0.5 ng/ml, 9 had a PCT value >2-10 ng/ml and 1 had a PCT value >10 ng/ml. The sensitivity of PCT was calculated to be 0.14. The mean WBC value was 13.0/nl (+/- 5.2, 3.4-31), and for CRP it was 8.8 mg/dl (+/- 13, 0-60.2). The values of CRP, WBC and PCT increased with the severity of the appendicitis.

CONCLUSIONS

PCT is potentially increased in rare cases of severe inflammation and, in particular, after appendiceal perforation or gangrenous appendicitis. However, its remarkably low sensitivity prohibits its routine use for the diagnosis of appendicitis.