Clinical controversies in abdominal sepsis. Insights for critical care settings

Influence of dental status on postoperative complications in major visceral surgical and organ transplantation procedures-the bellydent retrospective observational study

PURPOSE

The significance of dental status and oral hygiene on a range of medical conditions is well-recognised. However, the correlation between periodontitis, oral bacterial dysbiosis and visceral surgical outcomes is less well established. To this end, we study sought to determine the influence of dental health and oral hygiene on the rates of postoperative complications following major visceral and transplant surgery in an exploratory, single-center, retrospective, non-interventional study.

METHODS

Our retrospective non-interventional study was conducted at the Department of General, Visceral, and Transplant Surgery, University Hospital Heidelberg, Germany. Patients operated on between January 2018 and December 2019 were retrospectively enrolled in the study based on inclusion (minimum age of 18 years, surgery at our Department, intensive care / IMC treatment after major surgery, availability of patient-specific preoperative dental status assessment, documentation of postoperative complications) and exclusion criteria (minor patients or legally incapacitated patients, lack of intensive care or intermediate care (IMC) monitoring, incomplete documentation of preoperative dental status, intestinal surgery with potential intraoperative contamination of the site by intestinal microbes, pre-existing preoperative infection, absence of data regarding the primary endpoints of the study). The primary study endpoint was the incidence of postoperative complications. Secondary study endpoints were: 30-day mortality, length of hospital stay, duration of intensive care stay, Incidence of infectious complications, the microbial spectrum of infectious complication. A bacteriology examination was added whenever possible (if and only if the examination was safe for the patient)for infectious complications.

RESULTS

The final patient cohort consisted of 417 patients. While dental status did not show an influence (p = 0.73) on postoperative complications, BMI (p = 0.035), age (p = 0.049) and quick (p = 0.033) were shown to be significant prognostic factors. There was significant association between oral health and the rate of infectious complications for all surgical procedures (p = 0.034), excluding transplant surgery. However, this did not result in increased 30-day mortality rates, prolonged intensive care unit treatment or an increase in the length of hospital stay (LOS) for the cohort as a whole. In contrast there was a significant correlation between the presence of oral pathogens and postoperative complications for a group as a whole (p < 0.001) and the visceral surgery subgroup (p < 0.001). Whilst this was not the case in the cohort who underwent transplant surgery, there was a correlation between oral health and LOS in this subgroup (p = 0.040). Bacterial swabs supports the link between poor oral health and infectious morbidity.

CONCLUSIONS

Dental status was a significant predictor of postoperative infectious complications in this visceral surgery cohort. This study highlights the importance preoperative dental assessment and treatment prior to major surgery, particularly in the case of elective surgical procedures. Further research is required to determine the effect of oral health on surgical outcomes in order to inform future practice.

TRIAL REGISTRATION

Trial registered under the ethics-number S-082/2022 (Ethic Committee of the University Heidelberg).

Importance of timely and adequate source control in sepsis and septic shock

Source control is defined as the physical measures undertaken to eliminate the source of infection and control ongoing contamination, as well as restore anatomy and function at the site of infection. It is a key component of the management of patients with sepsis and septic shock and one of the main determinants of the outcome of infections that require source control. While not all infections may require source control, it should be considered in every patient presenting with sepsis; it is applicable and necessary in numerous infections, not only those occurring in the abdominal cavity. Although the biological rationale is clear, several aspects of source control remain under debate. The timing of source control may impact outcome; early source control is particularly relevant for patients with abdominal infections or necrotizing skin and soft tissue infections, as well as for those with more severe disease. Percutaneous procedures are increasingly used for source control; nevertheless, surgery-tailored to the patient and infection-remains a valid option for source control. For outcome optimization, adequate source control is more important than the strategy used. It should be acknowledged that source control interventions may often fail, posing a challenge in this setting. Thus, an individualized, multidisciplinary approach tailored to the infection and patient is preferable.

Molecular antimicrobial susceptibility testing in sepsis

Rapidly detecting and identifying pathogens is crucial for appropriate antimicrobial therapy in patients with sepsis. Conventional diagnostic methods have been a great asset to medicine, though they are time consuming and labor intensive. This work will enable healthcare professionals to understand the bacterial community better and enhance their diagnostic capacity by using novel molecular methods that make obtaining quicker, more precise results possible. The authors discuss and critically assess the merits and drawbacks of molecular testing and the added value of these tests, including the shift turnaround time, the implication for clinicians' decisions, gaps in knowledge, future research directions and novel insights or innovations. The field of antimicrobial molecular testing has seen several novel insights and innovations to improve the diagnosis and management of infectious diseases.

CLINICAL CHARACTERISTICS AND PREDICTORS OF MORTALITY DIFFER BETWEEN PULMONARY AND ABDOMINAL SEPSIS

ABSTRACT

Background: Pulmonary sepsis and abdominal sepsis have pathophysiologically distinct phenotypes. This study aimed to compare their clinical characteristics and predictors of mortality. Methods: In this multicenter retrospective trial, 1,359 adult patients who fulfilled the Sepsis-3 criteria were enrolled and classified into the pulmonary sepsis or abdominal sepsis groups. Plasma presepsin was measured, and the scores of Acute Physiology and Chronic Health Evaluation (APACHE) II, Mortality in Emergency Department Sepsis (MEDS), and Simplified Acute Physiology Score (SAPS) II were calculated at enrollment. Data on 28-day mortality were collected for all patients. Results: Compared with patients with abdominal sepsis (n = 464), patients with pulmonary sepsis (n = 895) had higher 28-day mortality rate, illness severity scores, incidence of shock and acute kidney injury, and hospitalization costs. Lactate level and APACHE II and MEDS scores were independently associated with 28-day mortality in both sepsis types. Independent predictors of 28-day mortality included Pa o2 /F io2 ratio (hazard ratio [HR], 0.998; P < 0.001) and acute kidney injury (HR, 1.312; P = 0.039) in pulmonary sepsis, and SAPS II (HR, 1.037; P = 0.017) in abdominal sepsis. A model that combined APACHE II score, lactate, and MEDS score or SAPS II score had the best area under the receiver operating characteristic curve in predicting mortality in patients with pulmonary sepsis or abdominal sepsis, respectively. Interaction term analysis confirmed the association between 28-day mortality and lactate, APACHE II score, MEDS score, SAPS II score, and shock according to the sepsis subgroups. The mortality of patients with pulmonary sepsis was higher than that of patients with abdominal sepsis among patients without shock (32.9% vs. 8.8%; P < 0.001) but not among patients with shock (63.7 vs. 48.4%; P = 0.118). Conclusions: Patients with pulmonary sepsis had higher 28-day mortality than patients with abdominal sepsis. The study identified sepsis subgroup-specific mortality predictors. Shock had a larger effect on mortality in patients with abdominal sepsis than in those with pulmonary sepsis.

Comparison of the PIPAS severity score tool and the QSOFA criteria for predicting in-hospital mortality of peritonitis in a tertiary hospital in Uganda: a prospective cohort study

BACKGROUND

The majority of the prognostic scoring tools for peritonitis are impractical in low resource settings because they are complex while others are quite costly. The quick Sepsis-related Organ Failure Assessment (qSOFA) score and the Physiologic Indicators for Prognosis in Abdominal Sepsis (PIPAS) severity score are two strictly bedside prognostic tools but their predictive ability for mortality of peritonitis is yet to be compared. We compared the predictive ability of the qSOFA criteria and the PIPAS severity score for in-hospital mortality of peritonitis.

METHOD

This was a prospective cohort study on consecutive peritonitis cases managed surgically in a tertiary hospital in Uganda between October 2020 to June 2021. PIPAS severity score and qSOFA score were assessed preoperatively for each case and all cases were then followed up intra- and postoperatively until discharge from the hospital, or up to 30 days if the in-hospital stay was prolonged; the outcome of interest was in-hospital mortality. We used Receiver Operating Characteristic curve analysis to assess and compare the predictive abilities of these two tools for peritonitis in-hospital mortality. All tests were 2 sided (p < 0.05) with 95% confidence intervals.

RESULTS

We evaluated 136 peritonitis cases. Their mean age was 34.4 years (standard deviation = 14.5). The male to female ratio was 3:1. The overall in-hospital mortality rate for peritonitis was 12.5%. The PIPAS severity score had a significantly better discriminative ability (AUC = 0.893, 95% CI 0.801-0.986) than the qSOFA score (AUC = 0.770, 95% CI 0.620-0.920) for peritonitis mortality (p = 0.0443). The best PIPAS severity cut-off score (a score of > = 2) had sensitivity and specificity of 76.5%, and 93.3% respectively, while the corresponding values for the qSOFA criteria (score > = 2), were 58.8% and 98.3% respectively.

CONCLUSIONS

The in-hospital mortality in this cohort of peritonitis cases was high. The PIPAS severity score tool has a superior predictive ability and higher sensitivity for peritonitis in-hospital mortality than the qSOFA score tool although the latter tool is more specific. We recommend the use of the PIPAS severity score as the initial prognostic tool for peritonitis cases in the emergency department.

The Role of Abdominal Drain Cultures in Managing Abdominal Infections

Intra-abdominal infections (IAI) are common in hospitalized patients, both in and outside of the intensive care unit. Management principles include antimicrobial therapy and source control. Typically, these infections are polymicrobial, and intra-operative samples will guide the targeted antimicrobial therapy. Although the use of prophylactic abdominal drains in patients undergoing abdominal surgery is decreasing, the use of drains to treat IAI, both in surgical and non-surgical strategies for abdominal infection, is increasing. In this context, samples from abdominal drains are often used to assist in antimicrobial decision making. In this narrative review, we provide an overview of the current role of abdominal drains in surgery, discuss the importance of biofilm formation in abdominal drains and the mechanisms involved, and review the clinical data on the use of sampling these drains for diagnostic purposes. We conclude that biofilm formation and the colonization of abdominal drains is common, which precludes the use of abdominal fluid to reliably diagnose IAI and identify the pathogens involved. We recommend limiting the use of drains and, when present, avoiding routine microbiological sampling.

The Host CYP1A1-Microbiota Metabolic Axis Promotes Gut Barrier Disruption in Methicillin-Resistant Staphylococcus aureus-Induced Abdominal Sepsis

Background

Host-microbiota crosstalk has been implicated in multiple host metabolic pathway axes that regulate intestinal barrier function. Although constitutive cytochrome P4501A1 (CYP1A1) expression perturbs the microbiome-derived autoregulatory loop following enteric infection, little is known about the role of host CYP1A1 in modulating gut microbiome-mediated signaling during methicillin-resistant Staphylococcus aureus (MRSA)-induced abdominal sepsis and its effects on intestinal barrier integrity.

Methods

Abdominal sepsis was induced by the intraperitoneal injection of MRSA in mice. The effect of CYP1A1 deficiency on gut barrier integrity was investigated using RNA sequencing, microbiome analyses, and targeted metabolomics. The microbiota-produced metabolites were validated in patients with sepsis and persistent MRSA infection.

Results

Mice lacking CYP1A1 exhibited an altered gut microbiome, a reduced metabolic shift from lysine to cadaverine in the caecal contents and antimicrobial molecule production (Retnlb, Gbp7, and Gbp3), and they were protected against gut barrier disruption when subjected to MRSA challenge. These beneficial effects were validated in aryl hydrocarbon receptor (AHR) knockout (KO) mice by cohousing with CYP1A1 KO mice and abrogated after supplementation with cadaverine or Enterococcus faecalis, the primary microbiota genus for cadaverine synthesis. Antibiotic-driven gut dysbacteriosis impaired the survival benefit and disrupted the intestinal barrier integrity in CYP1A1 KO mice after MRSA infection. Furthermore, increased cadaverine levels in feces and serum were detected in critically ill patients with gut leakiness during persistent MRSA infection, whereas cadaverine was not detected in healthy controls. Additionally, microbiota-derived cadaverine induced enterocyte junction disruption by activating the histamine H4 receptor/nuclear factor-κB/myosin light-chain kinase signaling pathway.

Conclusion

This study revealed the unexpected function of host CYP1A1 in microbiota-mediated cadaverine metabolism, with crucial consequences for dysbacteriosis following MRSA-induced abdominal sepsis, indicating that inhibiting CYP1A1 or blocking cadaverine-histamine H4 receptor signaling could be a potential therapeutic target against abdominal sepsis.

Clinical Trial Registration

[http://www.chictr.org.cn/index.aspx], identifier [ChiCTR1800018646].

Diffuse Appendicular Peritonitis: Laparoscopic vs Open Access — Viewpoint From Aside

The perforative acute appendicitis with the development of diffuse peritonitis increases the incidence of postoperative complications to 47%, and mortality to 3%. Mortality in the case of the development of diffuse purulent peritonitis makes 4.5-58%, and it can exceed 70% in severe forms of diffuse peritonitis with the development of infectious-toxic shock and multiple organ failure. National Clinical Guidelines for acute appendicitis with diffuse peritonitis allow for appendectomy from both the median and laparoscopic access in the absence of general contraindications to the creation of pneumoperitoneum. However, despite the proven advantages of laparoscopic appendectomy, there are opponents of its use in diffuse forms of appendicular peritonitis. An increased number of postoperative abscesses with a minimally invasive approach has been reported in literature; however, recent randomized studies refute this fact. There is also evidence that the laparoscopic method for appendicular peritonitis often leads to a lengthening of the operation time and higher operating costs, but at the same time there is a decrease in postoperative pain syndrome, a reduction in the length of inpatient treatment and early social and labor rehabilitation, which leads to an overall decrease in hospital costs. Thus, to date, there is no generally accepted opinion about the advisability of laparoscopic access for appendicular peritonitis. At the moment, the presence of diffuse peritonitis is the most common intraoperative reason for refusing a minimally invasive surgical treatment. However, there is a tendency to trying to standardize indications and contraindications, which was the objective of our literature review.

Metagenomic Next-Generation Sequencing for the Microbiological Diagnosis of Abdominal Sepsis Patients

Objectives

For patients with intra-abdominal infection (IAI), the rapid and accurate identification of pathogens remains a challenge. Metagenomic next-generation sequencing (mNGS) is a novel technique for infectious diseases, but its application in IAI is limited. In this study, we compared the microbiological diagnostic ability of plasma mNGS with that of conventional peritoneal drainage (PD) culture in critical care settings.

Methods

From January 2018 to December 2020, a prospective observational study was performed at a tertiary teaching hospital in China and data on 109 abdominal sepsis patients were collected. The pathogen detection performance of plasma mNGS and PD culture method were compared.

Measurements and Results

Ninety-two positive cases detected on PD culture, while plasma mNGS detected 61 positive cases. Forty-five patients (44.0%) had at least one matched pair of plasma mNGS and PD culture results. Compared with PD culture, the plasma mNGS was more rapid (27.1 ± 4.0 vs. 68.9 ± 22.3 h, p < 0.05). The patients received initial antibiotic treatment matched with mNGS detection showed better clinical outcomes.

Conclusion

For abdominal sepsis patients, plasma mNGS can provide early, noninvasive, and rapid microbiological diagnosis. Compared with conventional PD smear, culture, and blood culture methods, plasma mNGS promote the rapid detection of pathogenic bacteria.

Diagnostic challenges in postoperative intra-abdominal sepsis in critically ill patients: When to reoperate?

The present paper was done to review common diagnostic techniques used to help surgeons find the most suitable way to diagnose postoperative intra-abdominal sepsis (IAS). The topic was searched on MEDLINE, Embase, and Cochrane Library databases. Collected articles were classified and checked for their quality. Findings of selected research were included in this study and analyzed to find the best diagnostic method for intra-abdominal sepsis. IAS presents severe morbidity and mortality, and its early diagnosis can improve the outcome. Currently, there is no consensus among surgeons on a single diagnostic modality that should be used while deciding reoperation in patients with postoperative IAS. Though it has a high sensitivity for abdominal infections, computed tomography has limited applications due to mobility and time constraints. Diagnostic laparoscopy is a safe process that produces usable images, and can be used at the bedside. Diagnostic peritoneal lavage (DPL) has high sensitivity, and the patients testing positive through DPL can be subjected to exploratory laparotomy, depending on severity. Abdominal Reoperation Predictive Index (ARPI) is the only index reported as an aid for this purpose. Serial intra-abdominal pressure measurement has also emerged as a potential diagnostic tool. A proper selection of diagnostic modality is expected to improve the outcome in IAS, which presents high mortality risk and a limited time frame.

Initial antimicrobial management of sepsis

Sepsis is a common consequence of infection, associated with a mortality rate > 25%. Although community-acquired sepsis is more common, hospital-acquired infection is more lethal. The most common site of infection is the lung, followed by abdominal infection, catheter-associated blood steam infection and urinary tract infection. Gram-negative sepsis is more common than gram-positive infection, but sepsis can also be due to fungal and viral pathogens. To reduce mortality, it is necessary to give immediate, empiric, broad-spectrum therapy to those with severe sepsis and/or shock, but this approach can drive antimicrobial overuse and resistance and should be accompanied by a commitment to de-escalation and antimicrobial stewardship. Biomarkers such a procalcitonin can provide decision support for antibiotic use, and may identify patients with a low likelihood of infection, and in some settings, can guide duration of antibiotic therapy. Sepsis can involve drug-resistant pathogens, and this often necessitates consideration of newer antimicrobial agents.

Colon Ascendens Stent Peritonitis (CASP )

Colon ascendens stent peritonitis (CASP) is one of the well-established models of experimental abdominal sepsis. In CASP surgery, an open link between the gut lumen and the abdominal cavity is created by placing a stent into the colon ascendens. This mimics well the insufficient intestinal anastomosis. It causes a continuous leakage of the gut contents into the peritoneum and leads therefore to peritonitis and sepsis. The abdominal cavity is opened under general anesthesia and a plastic stent is located through and sutured to the colonic wall. The septic severity in CASP models can be titrated by altering the size of the stent catheter. Therefore, CASP models with small stents sizes are suitable for long-term studies and studies with mild/moderate sepsis severity. Within 24 h, animals develop clinical signs of sepsis. Monitoring of the clinical state, sufficient analgesia, appropriate antibiotics and fluid resuscitation should be performed postoperatively.

Therapeutics on the clock: Circadian medicine in the treatment of chronic inflammatory diseases

The circadian clock is a collection of endogenous oscillators with a periodicity of ~ 24 h. Recently, our understanding of circadian rhythms and their regulation at genomic and physiologic scales has grown significantly. Knowledge of the circadian influence on biological processes has provided new possibilities for novel pharmacological strategies. Directly targeting the biological clock or its downstream targets, and/or using timing as a variable in drug therapy are now important pharmacological considerations. The circadian machinery mediates many aspects of the inflammatory response and, reciprocally, an inflammatory environment can disrupt circadian rhythms. Therefore, intense interest exists in leveraging circadian biology as a means to treat chronic inflammatory diseases such as sepsis, asthma, rheumatoid arthritis, osteoarthritis, and cardiovascular disease, which all display some type of circadian signature. The purpose of this review is to evaluate the crosstalk between circadian rhythms, inflammatory diseases, and their pharmacological treatment. Evidence suggests that carefully rationalized application of chronotherapy strategies - alone or in combination with small molecule modulators of circadian clock components - can improve efficacy and reduce toxicity, thus warranting further investigation and use.

Post-operative abdominal infections: epidemiology, operational definitions, and outcomes

Postoperative abdominal infections are an important and heterogeneous health challenge in intensive care units (ICU) and encompass postoperative infectious processes developing within the abdominal cavity that may be caused by either bacterial or fungal pathogens. In this narrative review, we discuss postoperative bacterial and fungal abdominal infections, covering also multidrug-resistant (MDR) pathogens. We also cover clinically preeminent aspects such as the definition of postoperative abdominal infections, which still remains difficult owing to their heterogeneity in patient characteristics, clinical presentation, ecology and antimicrobial treatment. With regard to treatment, modifiable factors such as source control and antimicrobial therapy play a key role in influencing the prognosis of postoperative abdominal infections, but several conditions may hamper their correct application; thus efforts should necessarily be devoted towards improving their appropriateness and timing. Hot topics regarding the characteristics and management of postoperative abdominal infections are discussed in this narrative review.