Age, microbiology and prognostic scores help to differentiate between secondary and tertiary peritonitis

Tertiary peritonitis: considerations for complex team-based care

Peritonitis, as a major consequence of hollow visceral perforation, anastomotic disruption, ischemic necrosis, or other injuries of the gastrointestinal tract, often drives acute care in the emergency department, operating room, and the ICU. Chronic critical illness (CCI) represents a devastating challenge in modern surgical critical care where successful interventions have fostered a growing cohort of patients with prolonged dependence on mechanical ventilation and other organ supportive therapies who would previously have succumbed much earlier in the acute phase of critical illness. An important subset of CCI patients are those who have survived an emergency abdominal operation, but who subsequently require prolonged open abdomen management complicated by persistent peritoneal space infection or colonization, fistula formation, and gastrointestinal (GI) tract dysfunction; these patients are described as having tertiary peritonitis (TP).The organ dysfunction cascade in TP terminates in death in between 30 and 64% of patients. This narrative review describes key-but not all-elements in a framework for the coordinate multiprofessional team-based management of a patient with tertiary peritonitis to mitigate this risk of death and promote recovery. Given the prolonged critical illness course of this unique patient population, early and recurrent Palliative Care Medicine consultation helps establish goals of care, support adjustment to changes in life circumstance, and enable patient and family centered care.

Tertiary peritonitis: A disease that should not be ignored

Intra-abdominal infections can be classified into uncomplicated or complicated (peritonitis). Peritonitis is divided into primary, secondary, and tertiary. Tertiary peritonitis is the less common but the most severe among peritonitis stratifications, being defined as a recurrent intra-abdominal infection that occurs 48 h after a well-succeeded control of a secondary peritonitis. This disease has a complex pathogenesis that is closely related to the capacity of the peritoneal cavity to activate immunological processes. Patients who progress to persistent peritonitis are at an increased risk of developing several infectious complications such as sepsis and multiple organ failure syndrome. Moreover, tertiary peritonitis remains an important cause of hospital death mainly among patients with associated risk factors. The microbiological profile of organisms causing tertiary peritonitis is often different from that observed in other types of peritonitis. In addition, there is a high prevalence of multidrug-resistant pathogens causing this condition, and an appropriate and successful clinical management depends on an early diagnosis, which can be made easier with the use of clinical scores presenting a good prediction value during the intensive care unit admission. Complementarily, immediate therapy should be performed to control the infectious focus and to prevent new recurrences. In this sense, the treatment is based on initial antimicrobial therapy and well-performed peritoneal drainage.

Microbial findings, sensitivity and outcome in patients with postoperative peritonitis a retrospective cohort study

BACKGROUND

Acute postoperative peritonitis resulting from previous abdominal surgery is still a severe and potentially fatal disease, which is associated with high morbidity and mortality. The aim of the present study was to evaluate patients' outcome after postoperative peritonitis and identify the most effective empiric antibiotic regimes.

METHODS

422 patients with acute postoperative peritonitis as a result to earlier abdominal operation (e.g. anastomotic leakage) were analyzed retrospectively focusing on the origin of the peritonitis, microbial flora and resistance patterns. Furthermore, mortality was estimated according to sensitivity results of the tested antibiotics.

RESULTS

In 50% of the patients, anastomotic leakage was located in the colon. The predominantly cultured microorganisms were Escherichia coli and Enterobacteriaceae. The combination of meropenem and vancomycin was effective in 96% of these microbes. The frequently used combinations of piperacillin/sulbactam and cefotaxime/metronidazole were effective in only 67% and 43%, respectively.

CONCLUSIONS

We were able to show that the currently used antibiotic regimes with piperacillin/sulbactam and cefotaxime/metronidazole are ineffective in a relevant number of patients with anastomotic leakage. Only meropenem or meropenem/vancomycin cover most of the microbes predominant in postoperative peritonitis.

MICROBIOLOGICAL SPECTRE OF TERTIARY PERITONITIS AS A COMPONENT OF ITS DIAGNOSTICS AND TREATMENT

The aim of the research was to investigate the microbial spectre of tertiary peritonits (TP) and its antibiotic resistance as the way to improve the diagnostics and treatment of TP. Materials and methods. Prospective research enrolled 109 patients with secondary peritonitis. Tertiary peritonitis developed in 18,3 % of cases. Samples of peritoneal exudate had been drawn upon index operation, relaparotomy and on the day of diagnosis of TP. Blood sampling was performed in patients with persistent fever, impaired consciousness, prolonged (>4 days) discharge from drainage tubes and on the 1st day of diagnosis of TP. Antibacterial susceptibility was evaluated using Hinton-Müller media. Results and discussion. Patients were divided into 2 groups: with secondary peritonitis (89) and with TP (20). In TP group, cultivation of 76,2 % of primary specimens resulted in replantable and identifiable growth, presenting a shift towards Gram-negative flora and higher incidence of Candida albicans. Following the development of TP, hemocultures were positive in 15,1 %, presented mainly by Proteus spp. and non-albicans Candida spp. Second-group carbapenems, tigecycline and piperacillin-tazobactam had shown the highest activity in pathogens of TP. Caspofungin proved to be the most potent antifungal agent, especially towards non-albicans Candida spp. Antibiotic resistance in TP group was marked in 63,8 %. Conclusions. Tertiary peritonitis is one of the most severe forms of abdominal sepsis with highest mortality. Causing pathogenic flora in case of TP is mainly Gram-negative and coccal with high rates of antibiotic resistance both in vitro and in vivo. Fungi, presented predominantly by Candida non-albicans substrains, show an increasing content in peritoneal exudate and major effect upon mortality in TP. In case of TP, a significant percent of peritoneal specimens do not provide any culture growth despite of observing stringent sampling, transportation and cultivation rules. Antimicrobial therapy of TP can never be standardized and should always be thoroughly based upon regular and proper peritoneal and blood sampling.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

BACKGROUND

Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

METHODS

Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

RESULTS

This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

SUMMARY

The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

Which cause of diffuse peritonitis is the deadliest in the tropics? A retrospective analysis of 305 cases from the South-West Region of Cameroon

BACKGROUND

Acute diffuse peritonitis is a common surgical emergency worldwide and a major contributor to non-trauma related death toll. Its causes vary widely and are correlated with mortality. Community acquired peritonitis seems to play a major role and is frequently related to hollow viscus perforation. Data on the outcome of peritonitis in the tropics are scarce. The aim of this study is to analyze the impact of tropic latitude causes of diffuse peritonitis on morbidity and mortality.

METHODS

We retrospectively reviewed the records of 305 patients operated on for a diffuse peritonitis in two regional hospitals in the South-West Region of Cameroon over a 7 years period. The contributions of various causes of peritonitis to morbidity and mortality were analyzed.

RESULTS

The diagnosis of diffuse peritonitis was suggested on clinical ground only in more than 93 % of cases. The most common causes of diffuse peritonitis included peptic ulcer perforation (n = 69), complications of acute appendicitis (n = 53) and spontaneous perforations of the terminal ileum (n = 43). A total of 142 complications were recorded in 96 patients (31.5 % complication rate). The most common complications included wound dehiscence, sepsis, prolonged paralytic ileus and multi-organ failure. Patients with typhoid perforation of the terminal ileum carried a significantly higher risk of developing a complication (p = 0.002). The overall mortality rate was 15.1 %. The most common cause of death was septic shock. Differential analysis of mortality of various causes of peritonitis indicated that the highest contributors to death toll were typhoid perforation of terminal ileum (34.7 % of deaths), post-operative peritonitis (19.5 %) and peptic ulcer perforation (15.2 %).

CONCLUSION

The diagnosis of diffuse peritonitis can still rely on clinical assessment alone in the absence of sophisticated imaging tools. Peptic ulcer and typhoid perforations are still major contributors to death toll. Patients presenting with these conditions require specific attention and prevention policies must be reinforced.

Dynamic changes of microbial flora and therapeutic consequences in persistent peritonitis

Introduction

Persistent peritonitis is a frequent complication of secondary peritonitis requiring additional reoperations and antibiotic therapy. This situation raises specific concerns due to microbiological changes in peritoneal samples, especially the emergence of multidrug-resistant (MDR) strains. Although this complication has been extensively studied, the rate and dynamics of MDR strains have rarely been analysed.

Methods

We compared the clinical, microbiological and therapeutic data of consecutive ICU patients admitted for postoperative peritonitis either without subsequent reoperation (n = 122) or who underwent repeated surgery for persistent peritonitis with positive peritoneal fluid cultures (n = 98). Data collected on index surgery for the treatment of postoperative peritonitis were compared between these two groups. In the patients with persistent peritonitis, the data obtained at the first, second and third reoperations were compared with those of index surgery. Risk factors for emergence of MDR strains were assessed.

Results

At the time of index surgery, no parameters were able to differentiate patients with or without persistent peritonitis except for increased severity and high proportions of fungal isolates in the persistent peritonitis group. The mean time to reoperation was similar from the first to the third reoperation (range: 5 to 6 days). Septic shock was the main clinical expression of persistent peritonitis. A progressive shift of peritoneal flora was observed with the number of reoperations, comprising extinction of susceptible strains and emergence of 85 MDR strains. The proportion of patients harbouring MDR strains increased from 41% at index surgery, to 49% at the first, 54% at the second (P = 0.037) and 76% at the third reoperation (P = 0.003 versus index surgery). In multivariate analysis, the only risk factor for emergence of MDR strains was time to reoperation (OR 1.19 per day, 95%CI (1.08 to 1.33), P = 0.0006).

Conclusions

Initial severity, presence of Candida in surgical samples and inadequate source control are the major risk factors for persistent peritonitis. Emergence of MDR bacteria is frequent and increases progressively with the number of reoperations. No link was demonstrated between emergence of MDR strains and antibiotic regimens, while source control and its timing appeared to be major determinants of emergence of MDR strains.

An introduction of Tertiary Peritonitis

Intraperitoneal infection known as peritonitis is a major killer in the practice of clinical surgery. Tertiary peritonitis (TP) may be defined as intra-abdominal infection that persists or recurs ³48 h following successful and adequate surgical source control. A planned or on-demand relaparotomy after an initial operation is probably most frequent way to diagnose TP, but is a late event to occur. Hence it is desirable to have timely and nonoperative diagnosis of TP after the initial operation and subsequent initiation of an appropriate therapy to reduce the complications and to improve the outcome.

Intraabdominal Infections in the Intensive Care Unit

Intraabdominal infections are frequent and dangerous entity in intensive care units. Mortality and morbidity are high, causes are numerous, and treatment options are variable. The intensivist is challenged to recognize and treat intraabdominal infections in a timely fashion to prevent complications and death. Diagnosis of intraabdominal infection is often complicated by confounding underlying disease or masked by overall comorbidity. Current research describes a wide heterogeneity of patient populations, making it difficult to suggest a general treatment regimen and stressing the need of an individualized approach to decision making. Early focus-oriented intervention and antibiotic coverage tailored to the individual patient and hospital is warranted.

A focus on intra-abdominal infections

Complicated intra-abdominal infections are an important cause of morbidity and are frequently associated with poor prognosis, particularly in higher risk patients.

Well defined evidence-based recommendations for intra-abdominal infections treatment are partially lacking because of the limited number of randomized-controlled trials.

Factors consistently associated with poor outcomes in patients with intra-abdominal infections include increased illness severity, failed source control, inadequate empiric antimicrobial therapy and healthcare-acquired infection.

Early prognostic evaluation of complicated intra-abdominal infections is important to select high-risk patients for more aggressive therapeutic procedures.

The cornerstones in the management of complicated intra-abdominal infections are both source control and antibiotic therapy.

The timing and the adequacy of source control are the most important issues in the management of intra-abdominal infections, because inadequate and late control of septic source may have a negative effect on the outcomes.

Recent advances in interventional and more aggressive techniques could significantly decrease the morbidity and mortality of physiologically severe complicated intra-abdominal infections, even if these are still being debated and are yet not validated by limited prospective trials.

Empiric antimicrobial therapy is nevertheless important in the overall management of intra-abdominal infections. Inappropriate antibiotic therapy may result in poor patient outcomes and in the appearance of bacterial resistance.

Antimicrobial management is generally standardised and many regimens, either with monotherapy or combination therapy, have proven their efficacy. Routine coverage especially against Enterococci and candida spp is not always recommended, but can be useful in particular clinical conditions. A de escalation approach may be recommended in patients with specific risk factors for multidrug resistant infections such as immunodeficiency and prolonged antibacterial exposure.

Therapy should focus on the obtainment of adequate source control and adequate use of antimicrobial therapy dictated by individual patient risk factors. Other critical issues remain debated and more controversies are still open mainly because of the limited number of randomized controlled trials.

Identification of patients at risk for development of tertiary peritonitis on a surgical intensive care unit

BACKGROUND

Tertiary peritonitis (TP) is defined as a severe recurrent or persistent intra-abdominal infection after adequate surgical source control of secondary peritonitis (SP). The aim of this study was to analyze the characteristics of patients with SP who will further develop TP in order to define early diagnostic markers for TP.

STUDY DESIGN

Over a 1-year period, all patients on the surgical intensive care unit (ICU) with SP were prospectively assessed for the development of TP applying the definition of the ICU consensus conference. The Mannheim Peritonitis Index (MPI), C-reactive protein (CRP) and Simplified Acute Physiology Score II (SAPS II) were assessed at the initial operation (IO) that was diagnostic for SP and in the postoperative period.

RESULTS

Among 69 patients with SP, 15 patients further developed TP, whereas 54 patients did not develop TP. Compared to SP, patients with transition to TP had significantly higher MPI at IO (28.6 vs. 19.8; p < 0.001), relaparotomy rate (2.00 vs. 0.11; p < 0.001), mortality (60% vs. 9%; p < 0.001), duration of ICU stay (14 vs. 4 days; p < 0.005), as well as SAPS II (45.1 vs. 28.4; p < 0.005) and CRP (265 mg/dL vs. 217 mg/dL; p < 0.05) on the second postoperative day after IO.

CONCLUSIONS

The MPI at IO as well as CRP and SAPS II at the second postoperative day helps to identify patients at risk for tertiary peritonitis.