Intraabdominal Infections in Older Adults

Comparison of the efficacy of cefoperazone-sulbactam and other cephalosporins in the treatment of infections: A systematic review and meta-analysis

BACKGROUND

Cefoperazone-sulbactam is a broad-spectrum antibiotic known for its activity against a wide range of pathogens, including multidrug-resistant organisms (MDROs). This systematic review and meta-analysis aim to compare the efficacy and safety of cefoperazone-sulbactam with other cephalosporins in the treatment of infections.

METHODS

We conducted a comprehensive search of PubMed, Web of Science, Scopus, Cochrane Library, Medline, EMBASE, and CNKI databases for relevant studies up until July 11, 2024. Randomized controlled trials (RCTs) that compared cefoperazone-sulbactam with other cephalosporins in treating infections were included. Data were analyzed using RevMan 5.3 software, and the relative risk (RR) and mean difference (MD) were calculated. Sensitivity analysis and subgroup analyses were performed to ensure result robustness.

RESULTS

Seven RCTs involving 1017 patients were included in the analysis. Cefoperazone-sulbactam demonstrated a significantly higher treatment success rate (RR = 1.08, 95% CI [1.02-1.13], P = .003) and superior microbial clearance rate (RR = 1.22, 95% CI [1.11-1.34]) compared to other cephalosporins. Sensitivity analyses confirmed the stability of these findings. Adverse reactions were similar between groups, with cefoperazone-sulbactam demonstrating good safety and tolerability.

CONCLUSION

Cefoperazone-sulbactam shows superior efficacy compared to other cephalosporins in the treatment of infections, particularly in cases involving multidrug-resistant organisms. It also exhibits a comparable safety profile, making it a valuable option in clinical practice. However, further multicenter RCTs are needed to fully assess its potential in broader clinical applications.

Development and validation of a nomogram to predict postsurgical intra-abdominal infection in blunt abdominal trauma patients: A multicenter retrospective study

BACKGROUND

Intra-abdominal infection is a common complication of blunt abdominal trauma. Early detection and intervention can reduce the incidence of intra-abdominal infection and improve patients' prognoses. This study aims to construct a clinical model predicting postsurgical intra-abdominal infection after blunt abdominal trauma.

METHODS

This study is a retrospective analysis of 553 patients with blunt abdominal trauma from the Department of General Surgery of 7 medical centers (2011-2021). A 7:3 ratio was used to assign patients to the derivation and validation cohorts. Patients were divided into 2 groups based on whether intra-abdominal infection occurred after blunt abdominal trauma. Multivariate logistic regression and least absolute shrinkage and selection operator regression were used to select variables to establish a nomogram. The nomogram was evaluated, and the validity of the model was further evaluated by the validation cohort.

RESULTS

A total of 113 were diagnosed with intra-abdominal infection (20.4%). Age, prehospital time, C-reactive protein, injury severity score, operation duration, intestinal injury, neutrophils, and antibiotic use were independent risk factors for intra-abdominal infection in blunt abdominal trauma patients (P < .05). The area under the receiver operating curve (area under the curve) of derivation cohort and validation cohort was 0.852 (95% confidence interval, 0.784-0.912) and 0.814 (95% confidence interval, 0.751-0.902). The P value for the Hosmer-Lemeshow test was .135 and .891 in the 2 cohorts. The calibration curve demonstrated that the nomogram had a high consistency between prediction and practical observation. The decision curve analysis also showed that the nomogram had a better potential for clinical application. To facilitate clinical application, we have developed an online at https://nomogramcgz.shinyapps.io/IAIrisk/.

CONCLUSION

The nomogram is helpful in predicting the risk of postoperative intra-abdominal infection in patients with blunt abdominal trauma and provides guidance for clinical decision-making and treatment.

Preoperative standardized phase angle at bioimpedance vector analysis predicts the outbreak of antimicrobial-resistant infections after major abdominal oncologic surgery: A prospective trial

OBJECTIVES

Infectious morbidity is the most common and costly among all surgery-related complications, and infections by multidrug-resistant microorganisms (MDR) are associated with poor outcomes. Derangements of body composition is a recognized risk factor for infections. The aim of this study was to investigate the potential association between specific traits of body composition and the risk of having MDR-related infections.

METHODS

This was a prospective study with patients scheduled for major abdominal surgery for gastrointestinal cancer. Bioimpedance vector analysis (BIVA), a reliable tool for body composition assessment, was performed the day before the operation. Postoperative complications were collected focusing on resistance patterns and site of infection. Patterns of resistance were compared with BIVA parameters.

RESULTS

Data from 182 patients suffering from pancreatic (n = 76, 41.7%), rectal (n = 38, 20.9%), gastric (n = 31, 17%), or hepatic (n = 37, 20.3%) malignancy were collected. Overall complications occurred in 108 patients (59%), and in 45 patients (28%) bacterial infections were proven at culture. Of these, 15 (8%) were multidrug-sensitive (MDS), 38 MDR, and 2 extended drug-resistant (XDR) infections. The standardized phase angle measured (SPA) at BIVA was significantly lower in the MDR/XDR infections (-0.02 ± 1.20) than for no infection/MDS (0.56 ± 1.53; P = 0.029). A multivariate analysis showed that SPA was the only independent variable for MDR/XDR infections with an odds ratio of 3.057 (95% confidence interval, 1.354-6903; P = 0.007). The predictive ability of SPA revealed an area under the receiver operating characteristic curve of 0.662, with an optimal threshold of -0.3.

CONCLUSIONS

In surgical cancer patients, preoperative value of SPA lower than -0.3 is associated with the outbreak of MDR bacterial infections.

Novel Multiparametric Nomogram for Overall Survival Prediction in Complicated Intra-Abdominal Infection: A Multicenter Study in China

Background: Complicated intra-abdominal infections (cIAIs) in the abdominal cavity or within an abdominal organ are numerous and frequent dangerous entities in the treatment of critically ill patients. Early clinical evaluation is necessary.

Methods: This retrospective multicenter study included patients from 10 intensive care units (ICUs). Risk factors for the overall survival (OS) of patients with cIAI were selected using least absolute shrinkage and selection operator regression, and a nomogram was constructed subsequently. Calibration curve and receiver operating characteristic (ROC) curve were used to evaluate the calibration and discriminative ability.

Results: In total, 544 patients diagnosed with cIAI were enrolled and divided into the study (n = 276) and validation (n = 268) sets. Sex, acute gastrointestinal injury, acute kidney injury, rare bacterium infection, Charlson score, and APACHE II score were identified as independent risk factors and were constructed for the nomogram. The nomogram showed marked calibration capability with a concordance index (C-index) of 0.909 and 0.831 in the study and validation set, respectively. Compared with the common clinical prognostic scoring system, the nomogram achieved the highest discrimination ability with an area under the curve (AUC) value of 0.91 and 0.83 in the study set and validation set, respectively.

Conclusions: Our newly constructed nomogram provides a useful tool for risk stratification and prognosis evaluation of cIAI.

Carbapenems vs tigecycline for the treatment of complicated intra-abdominal infections: A Bayesian network meta-analysis of randomized clinical trials

BACKGROUND

Complicated intra-abdominal infections (cIAIs) are common in clinical practice, caused by a mixture of aerobic and anaerobic bacteria, increase the risk of mortality. Carbapenems and tigecycline (TGC) are recommended for antimicrobial therapies for cIAIs.

OBJECTIVE

To compare the effectiveness and safety of different carbapenems vs TGC for the treatment of cIAIs.

METHODS

PubMed, Embase, Medline (via Ovid SP) and Cochrane library databases were systematically searched. We included randomized controlled trials (RCTs) comparing different carbapenems vs TGC for the treatment of cIAIs. The pooled odds ratio (OR) with 95% credible interval (CrI) was calculated by Markov chain Monte Carlo methods. We estimated summary ORs using pairwise and network meta-analysis with random effects.

RESULTS

Fifteen studies involving 6745 participants were included in the analysis. Five different carbapenems and TGC were ultimately evaluated in this study. Although, the efficacy of carbapenems and TGC by ORs with corresponding 95% CrIs had not yet reached statistical differences, the cumulative rank probability indicated that clinical treatment success from best to worst was doripenem (DOPM), meropenem (MEPM), imipenem/cilastatin (IC), biapenem (BAPM), TGC and imipenem/cilastatin/relebactam (ICRB); microbiological treatment success from best to worst was DOPM, MEPM, IC, BAPM, ICRB and TGC. As for the risk of adverse events (AEs), TGC showed higher risk of AEs compared with IC (OR = 1.53, 95% CrI = 1.02-2.41), the remain antibiotic agents from lower to higher was MEPM, IC, BAPM, DOPM, ICRB and TGC. The risk of mortality from lower to higher was BAPM, DOPM, MEPM, IC, TGC and ICRB.

CONCLUSION

No differences in clinical and microbiological outcomes were observed between different carbapenems and TGC. Balancing the evidence for drug efficacy and side effects, DOPM appears to be the best available treatment for cIAIs. Therefore, it is reasonable to consider that DOPM is one of the best carbapenem monotherapy for cIAIs. MEPM and IC was also associated with higher rates of clinical and microbiological treatment success following DOPM. Empiric antimicrobial treatment of patients with cIAIs should be selected in light of the local bacterial epidemiology and patterns of resistance.

Carbapenems vs β-Lactam Monotherapy or Combination Therapy for the Treatment of Complicated Intra-abdominal Infections: Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

Complicated intra-abdominal infections (cIAIs) result in significant morbidity, mortality, and cost. Carbapenem-resistant sepsis has increased dramatically in the last decade, resulting in infections that are difficult to treat and associated with high mortality rates. To prevent further antibacterial resistance, it is necessary to use carbapenem selectively. The objective of this study was to compare the effectiveness and safety of carbapenems vs alternative β-lactam monotherapy or combination therapy for the treatment of cIAIs.

Methods

The PubMed, Embase, Medline (via Ovid SP), and Cochrane library databases were systematically searched. We included randomized controlled trials (RCTs) comparing carbapenems vs alternative β-lactam monotherapy or combination therapy for the treatment of cIAIs.

Results

Twenty-two studies involving 7720 participants were included in the analysis. There were no differences in clinical treatment success (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.71–1.05; I² = 35%), microbiological treatment success (OR, 0.88; 95% CI, 0.71–1.09; I² = 25%), adverse events (OR, 0.98; 95% CI, 0.87–1.09; I² = 17%), or mortality (OR, 0.96; 95% CI, 0.68–1.35; I² = 7%). Patients

treated with imipenem were more likely to experience clinical or microbiological failure than those treated with alternative β-lactam monotherapy or combination therapy.

Conclusions

No differences in clinical outcomes were observed between carbapenems and noncarbapenem β-lactams in cIAIs. Patients treated with imipenem were more likely to experience clinical or microbiological failure than those treated with alternative β-lactam monotherapy or combination therapy.

Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study

BACKGROUND

Frailty is a state of vulnerability to diverse stressors. We assessed the impact of frailty on outcomes after discharge in older surgical patients.

METHODS

We prospectively followed patients 65 years of age or older who underwent emergency abdominal surgery at either of 2 tertiary care centres and who needed assistance with fewer than 3 activities of daily living. Preadmission frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale as "well" (score 1 or 2), "vulnerable" (score 3 or 4) or "frail" (score 5 or 6). We assessed composite end points of 30-day and 6-month all-cause readmission or death by multivariable logistic regression.

RESULTS

Of 308 patients (median age 75 [range 65-94] yr, median Clinical Frailty Score 3 [range 1-6]), 168 (54.5%) were classified as vulnerable and 68 (22.1%) as frail. Ten (4.2%) of those classified as vulnerable or frail received a geriatric consultation. At 30 days after discharge, the proportions of patients who were readmitted or had died were greater among vulnerable patients (n = 27 [16.1%]; adjusted odds ratio [OR] 4.60, 95% confidence interval [CI] 1.29-16.45) and frail patients (n = 12 [17.6%]; adjusted OR 4.51, 95% CI 1.13-17.94) than among patients who were well (n = 3 [4.2%]). By 6 months, the degree of frailty independently and dose-dependently predicted readmission or death: 56 (33.3%) of the vulnerable patients (adjusted OR 2.15, 95% CI 1.01-4.55) and 37 (54.4%) of the frail patients (adjusted OR 3.27, 95% CI 1.32-8.12) were readmitted or had died, compared with 11 (15.3%) of the patients who were well.

INTERPRETATION

Vulnerability and frailty were prevalent in older patients undergoing surgery and unlikely to trigger specialized geriatric assessment, yet remained independently associated with greater risk of readmission for as long as 6 months after discharge. Therefore, the degree of frailty has important prognostic value for readmission.

TRIAL REGISTRATION FOR PRIMARY STUDY

ClinicalTrials.gov, no. NCT02233153.