Source control in the management of severe sepsis and septic shock: An evidence-based review

Source control in intra-abdominal infections: What you need to know

ABSTRACT

Providing optimal source control (SC) for intra-abdominal sepsis (IAS) is a critically important surgical principle, yet one that remains nebulous in terms of strict definitions and required conduct. The entire concept of SC has evolved in the last decades. Contemporary SC is not only surgical but also embraces minimally invasive percutaneous and medical therapies. We propose that adequate SC has evolved from the mere anatomical control of enteric leakage, cleansing of obvious contaminants and necrosis, to a more comprehensive anatomo-phyiological-biochemical model. While any breaches in the integrity of the gastrointestinal tract should be addressed urgently, SC should ultimately aim to control the generation and propagation of systemic biomediators, bacterial toxins, and toxic catabolites that perpetuate multisystem organ failure and death. Much urgently needs to be learned to understand and hopefully mitigate the dysbiotic influences of IAS on the human microbiome. Finally, the therapy offered should always be individualized, recognizing patient's unique pathophysiology, clinical condition, comorbidities, and predeclared preferences regarding invasive therapies and life-support.

Stop-It Randomized Clinical Trial (RCT) for Intra-Abdominal Infection (IAI) Revisited: Multivariate Analyses To Identify Treatment Effects 4 Days Antibiotic Agents Versus Resolution Signs/Symptoms + 2 Days and Drivers of Outcomes

Background: The STOP-IT randomized clinical trial (RCT) pioneered limiting antibiotic agents in intra-abdominal infection (IAI) with adequate surgical source control, but NIH funding ended before an adequate power sample size was enrolled to determine equivalence between STOP-IT study regimens: four days of antibiotic agents (4-days) after source control versus antibiotic agents until resolution of signs and symptoms of IAI plus two days (standard of care [SOC]). The objective of this investigation was to identify possible significant treatment effects 4-days versus SOC, and independent variables defining and predicting outcomes. Methods: De-identified data from 518 STOP-IT subjects were analyzed retrospectively in two groups: 4-days (n = 258) and SOC (n = 260), and separately as one group (n = 518). Statistics: multivariate regression analysis, chi-squared, and simple Cohen kappa coefficient. Results: No pre-randomization variable predicted protocol FAILURE (surgical site infection, recurrent IAI, or death at 30 d) in 4-day subjects. APACHE II predicted SOC FAILURE, but no cut point determined treatment effect (AUC = 0.608). Both observations implied that FAILURE may not reflect patient outcomes. Additionally, Cohen kappa for FAILURE and hospitalization at 7, 14, and 21 days was weak (0.1154, 0.2084, and 0.1969, respectively) with high numbers of discordant values. Pre-randomization variables associated with hospitalization/discharge at days 7, 14, and 21: extra-abdominal infection 1 (p < 0.0001), APACHE II score (p < 0.0001), age (p = 0.006), and WBC maximum (p < 0.05). However, all of these pre-randomization variables did not predict FAILURE, except APACHE II. Conclusions: Poor Cohen kappa coefficients indicate STOP-IT FAILURE agreed only weakly with hospital/discharge at 7, 14, or 21 days, and is not a valid reliable endpoint in IAI or for determining success or failure of any treatment. Pre-randomization extra-abdominal infection, APACHE II score, age, and WBC maximum strongly predicted hospitalization, but only APACHE II predicted failure. The study should use the appropriate sample size calculation when doing an equivalence on the basis of the Two One-Sided Test design. RCTs in IAI need prospectively validated clinically reliable endpoints that align with known patient outcomes that determine success.

The Association Between Central Venous Pressure and Acute Kidney Injury Development in Patients with Septic Shock

Background: Sepsis-associated acute kidney injury (AKI) is linked to increased mortality and prolonged hospital stays. The exact relationship between central venous pressure (CVP) and AKI remains unclear. We explored the correlation between CVP and AKI in septic shock patients. Methods: This retrospective study included adult patients with septic shock admitted to Mayo Clinic Rochester between 2006 and 2018. CVP levels were measured at 6, 12, 24, and 48 h after the diagnosis of sepsis, and patients were stratified into two groups based on CVP levels (CVP < 8 or ≥8 mmHg). Results: Of 5600 patients with septic shock, 3128 patients without AKI on admission are included. One-thousand-and-ninety-eight patients (35.1%) developed AKI within a median of 4.4 days. The median CVP levels and frequency of elevated CVP at 6, 12, 24, and 48 h are significantly higher in the AKI group. Elevated CVP (≥8 mmHg) at 6, 12, 24, and 48 h is associated with AKI incidence, even after adjusting for mean arterial pressure (MAP) levels. This association, after multivariable adjustments, only remains significant at 12 h with an odds ratio (OR) of 1.60 (95% CI, 1.26-2.05), p < 0.001 and 48 h with an OR of 1.60 (95% CI, 1.29-1.99), p < 0.001. Conclusions: Our findings indicate that CVP ≥ 8 mmHg is strongly associated with an increased risk of AKI, even after adjusting for MAP at the 12 and 48 h time points. These findings underscore a critical 12 or 48h window for interventions to lower CVP.

Bioactive Adrenomedullin in Dogs with Sepsis and Septic Shock: A Prospective, Case-Control Study

Sepsis and septic shock are leading causes of morbidity and mortality in both humans and dogs, and early diagnosis is crucial for improving outcomes. This study aimed to evaluate bioactive adrenomedullin (bio-ADM) concentrations in dogs with septic shock (n = 25), dogs with sepsis without evidence of shock (n = 25), and healthy control dogs (n = 25). Plasma bio-ADM concentrations were measured using a human sandwich enzyme-linked immunosorbent assay and reported as median (interquartile range). Plasma bio-ADM concentrations were significantly higher in both septic groups compared to the healthy controls (all <22.4 pg/mL), but not significantly different between the septic shock (75.0 [28.7-115.0] pg/mL) and sepsis (30.7 [22.4-79.7] pg/mL) groups. Dogs with higher illness severity scores had significantly higher bio-ADM concentrations (93.1 [32.2-122.0] pg/mL) than those with lower scores (29.8 [22.4-71.2] pg/mL). However, bio-ADM concentrations did not differ between survivors (33.0 [22.7-76.7] pg/mL) and non-survivors (74.7 [26.1-123.2] pg/mL). Measurement of bio-ADM is a potential marker for canine sepsis, but not for the identification of septic shock, and may provide information on disease severity. Further studies, including those on non-infectious inflammatory conditions, are necessary to better understand the diagnostic utility of bio-ADM measurement and its potential role as a marker of treatment response in dogs with sepsis.

Clonal background and routes of plasmid transmission underlie antimicrobial resistance features of bloodstream Klebsiella pneumoniae

Bloodstream infections caused by the opportunistic pathogen Klebsiella pneumoniae are associated with adverse health complications and high mortality rates. Antimicrobial resistance (AMR) limits available treatment options, thus exacerbating its public health and clinical burden. Here, we aim to elucidate the population structure of K. pneumoniae in bloodstream infections from a single medical center and the drivers that facilitate the dissemination of AMR. Analysis of 136 short-read genome sequences complemented with 12 long-read sequences shows the population consisting of 94 sequence types (STs) and 99 clonal groups, including globally distributed multidrug resistant and hypervirulent clones. In vitro antimicrobial susceptibility testing and in silico identification of AMR determinants reveal high concordance (90.44-100%) for aminoglycosides, beta-lactams, carbapenems, cephalosporins, quinolones, and sulfonamides. IncF plasmids mediate the clonal (within the same lineage) and horizontal (between lineages) transmission of the extended-spectrum beta-lactamase gene blaCTX-M-15. Nearly identical plasmids are recovered from isolates over a span of two years indicating long-term persistence. The genetic determinants for hypervirulence are carried on plasmids exhibiting genomic rearrangement, loss, and/or truncation. Our findings highlight the importance of considering both the genetic background of host strains and the routes of plasmid transmission in understanding the spread of AMR in bloodstream infections.

Patterns, Outcomes and Economic Burden of Primary vs. Secondary Bloodstream Infections: A Single Center, Cross-Sectional Study

Bloodstream infections (BSIs) can be primary or secondary, with significant associated morbidity and mortality. Primary bloodstream infections (BSIs) are defined as infections where no clear infection source is identified, while secondary BSIs originate from a localized infection site. This study aims to compare patterns, outcomes, and medical costs between primary and secondary BSIs and identify associated factors. Conducted at the University Hospital of Patras, Greece, from May 2016 to May 2018, this single-center retrospective cohort study included 201 patients with confirmed BSIs based on positive blood cultures. Data on patient characteristics, clinical outcomes, hospitalization costs, and laboratory parameters were analyzed using appropriate statistical methods. Primary BSIs occurred in 22.89% (46 patients), while secondary BSIs occurred in 77.11% (155 patients). Primary BSI patients were younger and predominantly nosocomial, whereas secondary BSI was mostly community-acquired. Clinical severity scores (SOFA, APACHE II, SAPS, and qPitt) were significantly higher in primary compared to secondary BSI. The median hospital stay was longer for primary BSI (21 vs. 12 days, p < 0.001). Although not statistically significant, mortality rates were higher in primary BSI (43.24% vs. 26.09%). Total care costs were significantly higher for primary BSI (EUR 4388.3 vs. EUR 2530.25, p = 0.016), driven by longer hospital stays and increased antibiotic costs. This study underscores the distinct clinical and economic challenges of primary versus secondary BSI and emphasizes the need for prompt diagnosis and tailored antimicrobial therapy. Further research should focus on developing specific management guidelines for primary BSI and exploring interventions to reduce BSI burden across healthcare settings.

The Global Burden of Sepsis and Septic Shock

A dysregulated host response to infection causes organ dysfunction in sepsis and septic shock, two potentially fatal diseases. They continue to be major worldwide health burdens with high rates of morbidity and mortality despite advancements in medical care. The goal of this thorough review was to present a thorough summary of the current body of knowledge about the prevalence of sepsis and septic shock worldwide. Using widely used computerized databases, a comprehensive search of the literature was carried out, and relevant studies were chosen in accordance with predetermined inclusion and exclusion criteria. A narrative technique was used to synthesize the data that were retrieved. The review's conclusions show how widely different locations and nations differ in terms of sepsis and septic shock's incidence, prevalence, and fatality rates. Compared to high-income countries (HICs), low- and middle-income countries (LMICs) are disproportionately burdened more heavily. We talk about risk factors, comorbidities, and difficulties in clinical management and diagnosis in a range of healthcare settings. The review highlights the need for more research, enhanced awareness, and context-specific interventions in order to successfully address the global burden of sepsis and septic shock.

Importance of Source Control in the Subgroup of Intra-Abdominal Infections for Septic Shock Patients: Analysis of 390 Cases

Background

This study aimed to evaluate the epidemiology of septic shock (SS) associated with intraabdominal infections (IAI) as well as associated mortality and efficacy of early source control in a tertiary-care educational hospital.

Methods

Patients who had SS with IAI and consulted by Infectious Diseases consultants between December 2013 and October 2022 during night shifts in our centre were analyzed retrospectively.

Results

A total number of 390 patients were included. Overall, 30-day mortality was 42.5% on day 3, while day 14 and 30 mortality rates were 63.3% and 71.3%, respectively. Source control by surgical or percutaneous operation was performed in 123 of 390 cases (31.5%), and the mortality rate was significantly lower in cases that were performed source control at any time during SS (65/123-52.8% vs 213/267-79.8%, p<0.001). In 44 of 123 cases (35.7%), source control was performed during the first 12 hours, and mortality was significantly lower in this group versus others (24/44-54.5% vs 254/346-73.4%, p=0.009). On the other hand, female gender (p<0.001, odds ratio(OR)= 2.943, 95%CI=1.714-5.054), diabetes mellitus (p= 0.014, OR=2.284, 95%CI=1.179-4.424), carbapenem-resistant Gram-negative etiology (p=0.011, OR=4.386, 95%CI=1.398-13.759), SOFA≥10 (p<0.001, OR=3.036, 95%CI=1.802-5.114), lactate >3 mg/dl (p<0.001, OR=2.764, 95%CI=1.562-4.891) and lack of source control (p=0.001, OR=2.796, 95%CI=1.523-5.133) were significantly associated with 30-day mortality in logistic regression analysis.

Conclusion

Source control has a vital importance in terms of mortality rates for IAI-related septic shock patients. Our study underscores the need for additional research, as the present analysis indicates that early source control does not manifest as a protective factor in logistic regression.

Retrospective study of 189 cases of acute perforated peptic ulcer: safety and efficacy of over-the-scope-clip based endoscopic closure

BACKGROUND

To compare the clinical outcomes in patients with acute perforated peptic ulcer (PPU) treated with over-the-scope clip (OTSC), non-surgical, and surgical interventions, and to explore the effectiveness and safety of OTSC closure.

METHODS

Hospital stay, antibiotic use, diet resumption time, and mortality rate were analyzed retrospectively. Binary Logistic regression analysis was used to identify the risk factors influencing PPU complicated with sepsis.

RESULTS

Patients were divided into three treatment groups: OTSC (n = 62), non-surgical (n = 72), and surgical (n = 55) groups. The median time (IQR) from symptom onset to admission was 9.0 (4-23) h. 88.71% (55/62) of the patients in In the OTSC group underwent OTSC closure within 24 h (median [IQR] time: 14.5 [7.00-30.25] h). The perforation diameters in the OTSC and surgical groups were 9.87 mm ± 5.97 mm and 8.55 mm ± 6.17 mm, respectively. The median (IQR) hospital stays in the OTSC (9.50 [7.00-12.25] days) and non-surgical group (9.00[7.00-13.00]days) were similar (p > 0.05), but shorter than that in surgical group (12.00[10.00-16.00]days), (p < 0.05). The median duration of antibiotic use was shorter in the OTSC group (7.00[3.00-10.00]) than in the non-surgical group (9.00[7.00-11.00]) and surgical group (11.00[9.00-13.00]) ( p < 0.05); and the time to resume oral feeding was shorter in the OTSC group (4.00[2.00-5.25]) than in the non-surgical group (7.00[6.13-9.00]) and surgical group (8.00[6.53-10.00]), respectively ( p < 0.05). No mortality difference among groups (p = 0.109) was found. Lower albumin level at admission, older age, and elevated creatinine levels were associated with increased sepsis risk, with OR(95%CI) of 0.826 (0.687-0.993), 1.077 (1.005-1.154), and 1.025 (1.006-1.043), respectively (all p < 0.05).

CONCLUSION

OTSC closure improves clinical outcomes of acute PPU patients without sepsis. Age, hypoalbuminemia, and baseline renal dysfunction increase the risk of sepsis, while mortality was associated with sepsis and multiorgan dysfunction.

One-Hour Bundle Protocols for Surgical Sepsis and Septic Shock in Surgical Intensive Care Unit: Clinical Outcome Aspects in the Thai Context

BACKGROUND

Surgical sepsis is a syndrome occurring during the perioperative period with a high mortality rate. Since the one-hour bundle protocol was recommended to decrease sepsis-related morbidity and mortality in clinical practice, the protocol has been applied to surgical patients with sepsis and septic shock. However, clinical outcomes in these surgical patients remain unknown. Thus, this study aimed to compare survival outcomes in patients before and after the implementation of one-hour bundle care in clinical practice.

METHODS

In this prospective cohort study, 401 surgical patients with sepsis were divided into two groups, with 195 patients undergoing the one-hour bundle from December 25, 2021, to March 31, 2024, and 206 patients undergoing usual care from January 1, 2018, to December 24, 2021, before the one-hour bundle protocol was implemented by the Surviving Sepsis Campaign (SSC). Demographic data, treatment processes, and clinical outcomes were recorded.

RESULTS

After the one-hour bundle protocol was applied in surgical practice, the median survival time was significantly increased in surgical patients who underwent one-hour bundle care (95% confidence interval (CI): 12.32-19.68) (p= 0.016). Factors influencing the increase in the mortality rate were delays in fluid resuscitation of >2 hours, vasopressor initiation of >2 hours, and empirical antibiotics of >5 hours (p= 0.017, 0.028, and 0.008, respectively).

CONCLUSION

One-hour bundle care for surgical patients with sepsis resulted in an increased median survival time. Delays in fluid resuscitation (>2 hours), vasopressor initiation (>2 hours), and empirical antibiotics (>5 hours) were factors associated with mortality.

Prompt antimicrobial therapy and source control on survival and defervescence of adults with bacteraemia in the emergency department: the faster, the better

BACKGROUND

Bacteraemia is a critical condition that generally leads to substantial morbidity and mortality. It is unclear whether delayed antimicrobial therapy (and/or source control) has a prognostic or defervescence effect on patients with source-control-required (ScR) or unrequired (ScU) bacteraemia.

METHODS

The multicenter cohort included treatment-naïve adults with bacteraemia in the emergency department. Clinical information was retrospectively obtained and etiologic pathogens were prospectively restored to accurately determine the time-to-appropriate antibiotic (TtAa). The association between TtAa or time-to-source control (TtSc, for ScR bacteraemia) and 30-day crude mortality or delayed defervescence were respectively studied by adjusting independent determinants of mortality or delayed defervescence, recognised by a logistic regression model.

RESULTS

Of the total 5477 patients, each hour of TtAa delay was associated with an average increase of 0.2% (adjusted odds ratio [AOR], 1.002; P < 0.001) and 0.3% (AOR 1.003; P < 0.001) in mortality rates for patients having ScU (3953 patients) and ScR (1524) bacteraemia, respectively. Notably, these AORs were augmented to 0.4% and 0.5% for critically ill individuals. For patients experiencing ScR bacteraemia, each hour of TtSc delay was significantly associated with an average increase of 0.31% and 0.33% in mortality rates for overall and critically ill individuals, respectively. For febrile patients, each additional hour of TtAa was significantly associated with an average 0.2% and 0.3% increase in the proportion of delayed defervescence for ScU (3085 patients) and ScR (1266) bacteraemia, respectively, and 0.5% and 0.9% for critically ill individuals. For 1266 febrile patients with ScR bacteraemia, each hour of TtSc delay respectively was significantly associated with an average increase of 0.3% and 0.4% in mortality rates for the overall population and those with critical illness.

CONCLUSIONS

Regardless of the need for source control in cases of bacteraemia, there seems to be a significant association between the prompt administration of appropriate antimicrobials and both a favourable prognosis and rapid defervescence, particularly among critically ill patients. For ScR bacteraemia, delayed source control has been identified as a determinant of unfavourable prognosis and delayed defervescence. Moreover, this association with patient survival and the speed of defervescence appears to be augmented among critically ill patients.

Microbiological profile of patients treated for postoperative peritonitis: temporal trends 1999-2019

BACKGROUND

Temporal changes in the microbiological resistance profile have been reported in several life-threatening infections. However, no data have ever assessed this issue in postoperative peritonitis (POP). Our purpose was to assess the rate of multidrug-resistant organisms (MDROs) in POP over a two-decade period and to analyse their influence on the adequacy of empirical antibiotic therapy (EAT).

METHODS

This retrospective monocentric analysis (1999-2019) addressed the changes over time in microbiologic data, including the emergence of MDROs and the adequacy of EAT for all intensive care unit adult patients treated for POP. The in vitro activities of 10 antibiotics were assessed to determine the most adequate EAT in the largest number of cases among 17 antibiotic regimens in patients with/without MDRO isolates. Our primary endpoint was to determine the frequency of MDRO and their temporal changes. Our second endpoint assessed the impact of MDROs on the adequacy of EAT per patient and their temporal changes based on susceptibility testing. In this analysis, the subgroup of patients with MDRO was compared with the subgroup of patients free of MDRO.

RESULTS

A total of 1,318 microorganisms were cultured from 422 patients, including 188 (45%) patients harbouring MDROs. The growing proportions of MDR Enterobacterales were observed over time (p = 0.016), including ESBL-producing strains (p = 0.0013), mainly related to Klebsiella spp (p < 0.001). Adequacy of EAT was achieved in 305 (73%) patients. Decreased adequacy rates were observed when MDROs were cultured [p = 0.0001 vs. MDRO-free patients]. Over the study period, decreased adequacy rates were reported for patients receiving piperacillin/tazobactam in monotherapy or combined with vancomycin and imipenem/cilastatin combined with vancomycin (p < 0.01 in the three cases). In patients with MDROs, the combination of imipenem/cilastatin + vancomycin + amikacin or ciprofloxacin reached the highest adequacy rates (95% and 91%, respectively) and remained unchanged over time.

CONCLUSIONS

We observed high proportions of MDRO in patients treated for POP associated with increasing proportions of MDR Enterobacterales over time. High adequacy rates were only achieved in antibiotic combinations involving carbapenems and vancomycin, while piperacillin/tazobactam is no longer a drug of choice for EAT in POP in infections involving MDRO.

Evaluation of Abdominal Emergencies

Early primary assessment and abdominal examination can often be enough to triage the patient with abdominal pain into those with less severe underlying pathologic condition from those with more acute findings. A focused history of the patient can then allow the clinician to develop their differential diagnosis. Once the differential diagnoses are determined, diagnostic imaging and laboratory findings can help confirm the diagnosis and allow for expeditious treatment and intervention.

Source control in emergency general surgery: WSES, GAIS, SIS-E, SIS-A guidelines

Intra-abdominal infections (IAI) are among the most common global healthcare challenges and they are usually precipitated by disruption to the gastrointestinal (GI) tract. Their successful management typically requires intensive resource utilization, and despite the best therapies, morbidity and mortality remain high. One of the main issues required to appropriately treat IAI that differs from the other etiologies of sepsis is the frequent requirement to provide physical source control. Fortunately, dramatic advances have been made in this aspect of treatment. Historically, source control was left to surgeons only. With new technologies non-surgical less invasive interventional procedures have been introduced. Alternatively, in addition to formal surgery open abdomen techniques have long been proposed as aiding source control in severe intra-abdominal sepsis. It is ironic that while a lack or even delay regarding source control clearly associates with death, it is a concept that remains poorly described. For example, no conclusive definition of source control technique or even adequacy has been universally accepted. Practically, source control involves a complex definition encompassing several factors including the causative event, source of infection bacteria, local bacterial flora, patient condition, and his/her eventual comorbidities. With greater understanding of the systemic pathobiology of sepsis and the profound implications of the human microbiome, adequate source control is no longer only a surgical issue but one that requires a multidisciplinary, multimodality approach. Thus, while any breach in the GI tract must be controlled, source control should also attempt to control the generation and propagation of the systemic biomediators and dysbiotic influences on the microbiome that perpetuate multi-system organ failure and death. Given these increased complexities, the present paper represents the current opinions and recommendations for future research of the World Society of Emergency Surgery, of the Global Alliance for Infections in Surgery of Surgical Infection Society Europe and Surgical Infection Society America regarding the concepts and operational adequacy of source control in intra-abdominal infections.

STOP Signs: A Population-based Interrupted Time Series Analysis of Antibiotic Duration for Complicated Intraabdominal Infection Before and After the Publication of a Landmark RCT

OBJECTIVE

To determine if the STOP-IT randomized controlled trial changed antibiotic prescribing in patients with Complicated Intraabdominal Infection (CIAI).

SUMMARY OF BACKGROUND DATA

CIAI is common and causes significant morbidity. In May 2015, the STOP-IT randomized controlled trial showed equivalent outcomes between four-day and clinically determined antibiotic duration.

METHODS

This was a population-based retrospective cohort study using interrupted time series methods. The STOP-IT publication date was the exposure. Median duration of inpatient antibiotic prescription was the outcome. All adult patients admitted to four hospitals in Calgary, Canada between July 2012 and December 2018 with CIAI who survived at least four days following source control were included. Analysis was stratified by infectious source as appendix or biliary tract (group A) versus other (group B).

RESULTS

Among 4384 included patients, clinical and demographic attributes were similar before vs after publication. In Group A, median inpatient antibiotic duration was 3 days and unchanged from the beginning to the end of the study period [adjusted median difference -0.00 days, 95% confidence interval (CI) -0.37 - 0.37 days]. In Group B, antibiotic duration was shorter at the end of the study period (7.87 vs 6.73 days; -1.14 days, CI-2.37 - 0.09 days), however there was no change in trend following publication (-0.03 days, CI -0.16 - 0.09).

CONCLUSIONS

For appendiceal or biliary sources of CIAI, antibiotic duration was commensurate with the experimental arm of STOP-IT. For other sources, antibiotic duration was long and did not change in response to trial publication. Additional implementation science is needed to improve antibiotic stewardship.

Electro-microenvironment modulated inhibition of endogenous biofilms by piezo implants for ultrasound-localized intestinal perforation disinfection

Endogenous bacterial infections from damaged gastrointestinal (GI) organs have high potential to cause systemic inflammatory responses and life-threatening sepsis. Current treatments, including systemic antibiotic administration and surgical suturing, are difficult in preventing bacterial translocation and further infection. Here, we report a wireless localized stimulator composed of a piezo implant with high piezoelectric output serving as an anti-infective therapy patch, which aims at modulating the electro-microenvironment of biofilm around GI wounds for effective inhibition of bacterial infection if combined with ultrasound (US) treatment from outside the body. The pulsed charges generated by the piezo implant in response to US stimulation transfer into bacterial biofilms, effectively destroying their macromolecular components (e.g., membrane proteins), disrupting the electron transport chain of biofilms, and inhibiting bacterial proliferation, as proven by experimental studies and theoretical calculations. The piezo implant, in combination with US stimulation, also exhibits successful in vivo anti-infection efficacy in a rat cecal ligation and puncture (CLP) model. The proposed strategy, combining piezo implants with controllable US activation, creates a promising pathway for inhibiting endogenous bacterial infection caused by GI perforation.

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Poor timing and failure of source control are risk factors for mortality in critically ill patients with secondary peritonitis

PURPOSE

To describe data on epidemiology, microbiology, clinical characteristics and outcome of adult patients admitted in the intensive care unit (ICU) with secondary peritonitis, with special emphasis on antimicrobial therapy and source control.

METHODS

Post hoc analysis of a multicenter observational study (Abdominal Sepsis Study, AbSeS) including 2621 adult ICU patients with intra-abdominal infection in 306 ICUs from 42 countries. Time-till-source control intervention was calculated as from time of diagnosis and classified into 'emergency' (< 2 h), 'urgent' (2-6 h), and 'delayed' (> 6 h). Relationships were assessed by logistic regression analysis and reported as odds ratios (OR) and 95% confidence interval (CI).

RESULTS

The cohort included 1077 cases of microbiologically confirmed secondary peritonitis. Mortality was 29.7%. The rate of appropriate empiric therapy showed no difference between survivors and non-survivors (66.4% vs. 61.3%, p = 0.1). A stepwise increase in mortality was observed with increasing Sequential Organ Failure Assessment (SOFA) scores (19.6% for a value ≤ 4-55.4% for a value > 12, p < 0.001). The highest odds of death were associated with septic shock (OR 3.08 [1.42-7.00]), late-onset hospital-acquired peritonitis (OR 1.71 [1.16-2.52]) and failed source control evidenced by persistent inflammation at day 7 (OR 5.71 [3.99-8.18]). Compared with 'emergency' source control intervention (< 2 h of diagnosis), 'urgent' source control was the only modifiable covariate associated with lower odds of mortality (OR 0.50 [0.34-0.73]).

CONCLUSION

'Urgent' and successful source control was associated with improved odds of survival. Appropriateness of empirical antimicrobial treatment did not significantly affect survival suggesting that source control is more determinative for outcome.

Bacteremia and Late-Term Abortion Secondary to Salmonellosis in a Dog

A 5 yr old, 54-day-pregnant whippet presented for hyperthermia, lethargy, and spontaneous abortion of multiple fetuses. Blood work and clinical signs raised concern for uterine sepsis; therefore, the dog underwent an emergency ovariohysterectomy. Blood and uterine samples cultured a Salmonella species. Following ovariohysterectomy and oral antibiotic therapy, the dog had no further systemic signs. Repeat blood cultures and Salmonella testing were negative. To the authors' knowledge, this is the first report of a Salmonella species causing bacteremia in conjunction with late-term abortion in a dog.

Ceftolozane/tazobactam for difficult-to-treat Gram-negative infections: A real-world tertiary hospital experience

OBJECTIVE

To evaluate the real-world clinical efficacy of ceftolozane/tazobactam (C/T) in difficult-to-treat infections caused by multi-drug resistant Gram-negative microorganisms, including carbapenem-resistant Pseudomonas aeruginosa.

METHODS

Retrospective cohort study of adult patients treated with C/T for at least 48 hours for infections caused by multi-drug resistant Gram-negative bacteria in a tertiary hospital from May 2016 until August 2019. The primary outcome analysed was clinical failure, defined as a composite of symptomatology persistence after 7 days of C/T treatment, infection recurrence, and/or all-cause mortality within 30 days of follow-up.

RESULTS AND DISCUSSION

96 episodes of C/T treatment were included, mostly consisting of targeted treatments (83.9%) for the following sources of infection: intra-abdominal (22.6%), urinary tract (25.8%), skin and soft tissue (19.4%), hospital-acquired pneumonia (14%), and other (6.4%). The most frequently isolated bacteria were carbapenem-resistant (88, 94.6%). Clinical failure rate was 30.1%, due to persistent infection at day 7 (4.3%), recurrence of the initial infection (16.1%), or 30-day all-cause mortality (8.6%). Adverse events most frequently reported were Clostridium difficile infection (9%) and cholestasis (8%).

WHAT IS NEW AND CONCLUSION

C/T showed a favourable clinical profile for difficult-to-treat multidrug-resistant and carbapenem-resistant Gram-negative infections, regardless of the source of infection.

Absence of abdominal drainage after surgery for secondary lower gastrointestinal tract peritonitis is a valid strategy

BACKGROUND

Management of abdominal drainage after surgery for secondary lower gastrointestinal tract peritonitis (LGTP) is not a standardized procedure. A monocentric study was carried out in 2016 in our centre. (PI study) to evaluate the interest of drainage. Our objective was to revaluate, our actual use of abdominal drainage after peritonitis (PII study).

STUDY DESIGN

We examined retrospectively patients who underwent surgery for secondary sub-mesocolic community-acquired peritonitis (January 2016-December 2019). Study exclusion criteria were primary peritonitis, peritoneal dialysis, nosocomial peritonitis, postoperative peritonitis, upper gastrointestinal tract peritonitis, peritonitis due to appendicitis, peritonitis requiring the implementation of Mikulicz's drain, and peritonitis in which the peritoneum was not described in the surgical report (i.e., the same criteria that the PI study which included 141 patients from January 2009 to January 2012). The primary endpoint was the rate of abdominal drainage. The secondary endpoints were the patient rate without a peritoneum description, major complications rate (Clavien ≥III), abscess rate, mortality rate and the length of stay in the non-drain group (D - ) and in the drain group (D + ) in PII study. Primary and secondary endpoints were also compared between PI and PII studies. Risk factors for post-operative abscess were also research.

RESULTS

Of the 150 patients included 33% were drained vs 84% of the 141 patients included in PI study (p < 0.001). In PII study peritoneum was described in 80.3% of patients vs 69% in PI study (NS, p = 0.06). Comparing the two groups D -  and D + , no significant differences were found in major complications (respectively 45% vs 32%, p = 0.1), reoperation rate (respectively 25% vs 22%, p = 0.7), death rate (respectively 25% vs 14%; p = 0.1) and mean length of stay (respectively 12 days vs 13 days, p = 0.9). The abscess rate was significantly lower in the D -  group (10% vs 30%, p = 0.002). Comparing PI and PII studies, there was no difference about major complications (35% vs 35%, p = 0.1), reoperation (16% vs 17.5%, p = 0.5), abscess rate (15% vs 8.5%, p = 0.1) and mortality (14.5% vs 17.5%, p = 0.7). The length of stay was longer in PI study than in P II (14 days vs 9 days, p = 0.03). Drainage (p = 0.005; OR = 4.357; CI [1.559-12.173]) and peritonitis type (p = 0.032; OR = 3.264; CI [1.106-9.630]) were abscess risk factors.

CONCLUSION

This study therefore showed that drainage after surgery for LGTP may not be necessary and that, at least at the local level, surgeons seem to be inclined to discontinue it systematically. It may therefore be worthwhile to conduct a randomised control trial to establish recommendations on drainage after surgery for LGTP.

Risk factors for therapeutic failure in the management of post-operative peritonitis: a post hoc analysis of the DURAPOP trial

BACKGROUND

Therapeutic failure is a frequent issue in the management of post-operative peritonitis.

OBJECTIVES

A post hoc analysis of the prospective, multicentre DURAPOP trial analysed the risk factors for failures in post-operative peritonitis following adequate source control and empirical antibiotic therapy in critically ill patients.

PATIENTS AND METHODS

Overall failures assessed post-operatively between Day 8 and Day 45 were defined as a composite of death and/or surgical and/or microbiological failures. Risk factors for failures were assessed using logistic regression analyses.

RESULTS

Among the 236 analysed patients, overall failures were reported in 141 (59.7%) patients, including 30 (12.7%) deaths, 81 (34.3%) surgical and 95 (40.2%) microbiological failures. In the multivariate analysis, the risk factors associated with overall failures were documented piperacillin/tazobactam therapy [adjusted OR (aOR) 2.10; 95% CI 1.17-3.75] and renal replacement therapy on the day of reoperation (aOR 2.96; 95% CI 1.05-8.34). The risk factors for death were age (aOR 1.08 per year; 95% CI 1.03-1.12), renal replacement therapy on reoperation (aOR 3.95; 95% CI 1.36-11.49) and diabetes (OR 6.95; 95% CI 1.34-36.03). The risk factors associated with surgical failure were documented piperacillin/tazobactam therapy (aOR 1.99; 95% CI 1.13-3.51), peritoneal cultures containing Klebsiella spp. (aOR 2.45; 95% CI 1.02-5.88) and pancreatic source of infection (aOR 2.91; 95% CI 1.21-7.01). No specific risk factors were identified for microbiological failure.

CONCLUSIONS

Our data suggest a predominant role of comorbidities, the severity of post-operative peritonitis and possibly of documented piperacillin/tazobactam treatment on the occurrence of therapeutic failures, regardless of their type.

Source Identification of Klebsiella pneumoniae Causing Six Episodes of Recurrent Sepsis in an Adolescent That Underwent Hematopoietic Stem Cell Transplantation

Septicemia or bacteremia is one of the leading causes of death worldwide. Long-term tunneled central venous catheters (CVCs) are usually placed in children undergoing chemotherapy or hematopoietic stem cell transplantation (HSCT) for underlying hemato–oncologic malignancies. However, catheter-related complications have been reported frequently, and there is high morbidity and mortality related to catheter-line-associated bloodstream infections (CLABSIs). We report a rare case of six episodes of recurrent K. pneumoniae sepsis within a 6-month period in a 12-year-old male adolescent that underwent HSCT for acute lymphoblastic leukemia, despite treatment with susceptible antibiotics. The patient received extensive diagnostic evaluations to find the hidden source; however, failure to discover the primary source led to multiple recurrences. Through enterobacterial repetitive intergenic consensus (ERIC)-PCR, we were able to identify the relationship between the six episodes and recognize the source of bacteremia.

The Clinical Utility of Maceration Dressings in the Treatment of Inpatient Hand Infections: An Evaluation of Treatment Outcomes Compared to Standard Care

Background: In cases of oral antibiotic-resistant infection of the hand, we propose utilizing a heated, moist maceration dressing to help shorten and simplify the in-hospital clinical course by increasing the efficacy of antibiotic deliverance to infection sites, increasing the success of nonoperative management, and decreasing eradication time of infection of the hand. Methods: Fifty-six patients older than 18 years of age who presented with hand infections requiring inpatient intravenous antibiotics at our suburban academic hospital over a 30-month period were included and randomly assigned to either the maceration dressing group or the standard treatment group. Maceration dressings included warm and moist gauze, kerlix, webril, Orthoglass, Aqua K Pad, and sling. Results: Fifty-two patients who were mostly male and younger than 60 years of age were included. Patients who used the maceration dressing had significantly shorter hospital lengths of stay (P = .02) and intravenous antibiotics duration before transition to oral antibiotics (P = .04), and decreased need for formal operating room irrigation and debridement to obtain source control (P = .02) compared to patients treated with the standard dressing. Post-hoc analysis yielded improved outcomes when using the maceration dressing regardless of whether initial bedside incision and drainage was needed to decompress a superficial abscess or not. Conclusion: The maceration dressing can be used along with proper intravenous antibiotic treatment to improve the treatment course of patients with hand infections regardless of whether the patient needs an initial bedside incision and drainage or not. Level of Evidence: Therapeutic Level II.

Protective role of DJ-1 in endotoxin-induced acute kidney injury

Acute kidney injury (AKI) is a frequent complication of sepsis and an important cause of morbidity and mortality worldwide. A cornerstone of sepsis-associated AKI is dysregulated inflammation, leading to increased tissue oxidative stress and free radical formation, which leads to multiple forms of cell death. DJ-1 is a peroxiredoxin protein with multiple functions, including its ability to control cellular oxidative stress. Although DJ-1 is expressed prominently by renal tubules, its role in AKI has not been investigated. In the present study, we examined the effect of DJ-1 deficiency in a murine model of endotoxin-induced AKI. Endotoxemia induced greater kidney injury in DJ-1-deficient mice. Furthermore, DJ-1 deficiency increased renal oxidative stress associated with increased renal tubular apoptosis and with expression of death domain-associated protein (DAXX). Similar to the in vivo model, in vitro experiments using a medullary collecting duct cell line (mIMCD3) and cytotoxic serum showed that serum obtained from wild-type mice resulted in increased expression of s100A8/s100A9, DAXX, and apoptosis in DJ-1-deficient mIMCD3 cells. Our findings demonstrate a novel renal protective role for renal tubular DJ-1 during endotoxemia through control of oxidative stress, renal inflammation, and DAXX-dependent apoptosis.

Public Awareness of Sepsis Compared to Acute Myocardial Infarction and Stroke in Jeddah, Saudi Arabia: Questionnaire Study

BACKGROUND

Sepsis is a state of organ dysfunction caused by an impaired host response to infection. It is one of the leading causes of death globally. Sepsis, acute myocardial infarction (AMI), and stroke share the primary management requirement of rapid intervention. This could be achieved through early presentation to the hospital, which demands previous knowledge of the disease to ensure better outcomes.

OBJECTIVE

Our study aimed to assess the level of public awareness of sepsis compared with AMI and stroke.

METHODS

This was a cross-sectional survey study performed in June and July 2018, with 1354 participants from Jeddah, Saudi Arabia, aged ≥18 years. Data entry was performed using Microsoft Excel and statistical analysis including chi-square tests and multilogistic regression was performed using SPSS software.

RESULTS

A total of 1354 participants were included. Only 56.72% (768/1354) had heard of the term "sepsis" and 48.44% (372/768) of these participants were able to correctly identify it. In addition, 88.33% (1196/1354) had heard the term "myocardial infarction" and 64.63% (773/1196) knew the correct definition of that condition. Stroke was recognized by 81.46% (1103/1354) of participants and 59.20% (653/1103) of these participants correctly identified the condition. The difference between those who had heard of these diseases and those who knew the correct definition significantly differed from the values for awareness of sepsis and its definition.

CONCLUSIONS

We found that public awareness and knowledge of sepsis are poor amongst the population of Jeddah compared with the awareness and knowledge of AMI and stroke. This lack of knowledge may pose a serious obstruction to the prompt management needed to limit fatal outcomes.

Time to vasopressor initiation and organ failure progression in early septic shock

OBJECTIVE

Research evaluating the relationship between vasopressor initiation timing and clinical outcomes is limited and conflicting. We investigated the association between time to vasopressors, worsening organ failure, and mortality in patients with septic shock.

METHODS

This was a retrospective study of patients with septic shock (2013-2016) within 24 hours of emergency department (ED) presentation. The primary outcome was worsening organ failure, defined as an increase in Sequential Organ Failure Assessment (SOFA) score ≥2 at 48 hours compared to baseline, or death within 48 hours. The secondary outcome was 28-day mortality. Time to vasopressor initiation was categorized into 6, 4-hour intervals from time of ED triage. Multiple logistic regression was used to identify predictors of worsening organ failure.

RESULTS

We analyzed data from 428 patients with septic shock. There were 152 patients with the composite primary outcome (SOFA increase ≥2 or death at 48 hours). Of these, 77 patients died in the first 48 hours and 75 patients had a SOFA increase ≥2. Compared to the patients who received vasopressors in the first 4 hours, those with the longest time to vasopressors (20-24 hours) had increased odds of developing worsening organ failure (odds ratios [OR] = 4.34, 95% confidence intervals [CI] = 1.47-12.79, P = 0.008). For all others, the association between vasopressor timing and worsening organ failure was non-significant. There was no association between time to vasopressor initiation and 28-day mortality.

CONCLUSIONS

Increased time to vasopressor initiation is an independent predictor of worsening organ failure for patients with vasopressor initiation delays >20 hours.

In-depth analysis of T2Bacteria positive results in patients with concurrent negative blood culture: a case series

Background

T2Bacteria assay uses T2 magnetic resonance (T2MR) technology for the rapid diagnosis of bacterial bloodstream infections (BSIs). This FDA cleared technology can detect 5 of the most prevalent pathogens causing bacteremia (Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Enterococcus faecium). Because the significance of discordant results between the T2Bacteria assay and blood culture (BC) remains a challenge, in this case series we reviewed the medical records of patients who had a positive T2Bacteria test and a concurrent negative BC.

Methods

Among 233 participants, we identified 20 patients with 21 (9%) discordant T2Bacteria-positive/BC-negative (T2+/BC-) results. We classified these results based on clinical cultures and clinical evidence.

Results

When we analyzed these 21 discordant results in-depth, 11 (52.5%) fulfilled criteria for probable BSI, 4 (19%) for possible BSI, and 6 (28.5%) were presumptive false positives. Among the probable/possible BSIs, discordant results were often associated with patients diagnosed with closed space and localized infections [pyelonephritis (n = 7), abscess (n = 4), pneumonia (n = 1), infected hematoma (n = 1), and osteomyelitis (n = 1)]. Also, within the preceding 2 days of the T2+/BC- blood sample, 80% (16/20) of the patients had received at least one dose of an antimicrobial agent which was active against the T2Bacteria-detected pathogen.

Conclusions

In the majority of discrepant results, the T2Bacteria assay detected a plausible pathogen that was supported by clinical and/or microbiologic data. Discrepancies appear to be associated with closed space and localized infections and the recent use of effective antibacterial agents. The clinical significance and potential implications of such discordant results should be further investigated.

Open abdomen treatment for complicated intra-abdominal infection patients with gastrointestinal fistula can reduce the mortality

To evaluate the effect of the open abdomen (OA) and closed abdomen (CA) approaches for treating intestinal fistula with complicated intra-abdominal infection (IFWCIAI), and analyze the risk factors in OA treatment.IFWCIAI is associated with high mortality rates and healthcare costs, as well as longer postoperative hospital stay. However, OA treatment has also been linked with increased mortality and development of secondary intestinal fistula.A total of 195 IFWCIAI patients who were operated over a period of 7 years at our hospital were retrospectively analyzed. These patients were divided into the OA group (n = 112) and CA group (n = 83) accordingly, and the mortality rates, hospital costs, and hospital stay duration of both groups were compared. In addition, the risk factors in OA treatment were also analyzed.OA resulted in significantly lower mortality rates (9.8% vs 30.1%, P < .001) and hospital costs ($11721.40 ± $9368.86 vs $20365.36 ± $21789.06, P < .001) compared with the CA group. No incidences of secondary intestinal fistula was recorded and the duration of hospital stay was similar for both groups (P = .151). Delayed OA was an independent risk factor of death following OA treatment (hazard ratio [HR] = 1.316; 95% confidence interval [CI] = 1.068-1.623, P = .010), whereas early enteral nutrition (EN) exceeding 666.67 mL was a protective factor (HR = 0.996; 95% CI = 0.993-0.999, P = .018). In addition, Acinetobacter baumannii, Pseudomonas aeruginosa, and Candida albicans were the main pathogens responsible for the death of patients after OA treatment.OA decreased mortality rates and hospital costs of IFWCIAI patients, and did not lead to any secondary fistulas. Early OA and EN also reduced mortality rates.

Team Approach: Pediatric Musculoskeletal Infection

A team approach is optimal in the evaluation and treatment of musculoskeletal infection in pediatric patients given the complexity and uncertainty with which such infections manifest and progress, particularly among severely ill children. The team approach includes emergency medicine, pediatric intensive care, pediatric hospitalist medicine, infectious disease service, orthopaedic surgery, radiology, anesthesiology, pharmacology, and hematology. These services follow evidence-based clinical practice guidelines with integrated processes of care so that children and their families may benefit from data-driven continuous process improvement. Important principles based on our experience in the successful treatment of pediatric musculoskeletal infection include relevant information gathering, pattern recognition, determination of the severity of illness, institutional workflow management, closed-loop communication, patient and family-centered care, ongoing dialogue among key stakeholders within and outside the context of direct patient care, and periodic data review for programmatic improvement over time. Such principles may be useful in almost any setting, including rural communities and developing countries, with the understanding that the team composition, institutional capabilities or limitations, and specific approaches to treatment may differ substantially from one setting or team to another.

Use of Procalcitonin to Guide Discontinuation of Antimicrobial Therapy in Patients with Persistent Intra-Abdominal Collections: A Case Series

Objective

Limited evidence exists for the use of procalcitonin (PCT) to guide the duration of antimicrobial therapy in patients with intra-abdominal abscesses (IAA). In this case series, we describe clinical presentations and outcomes using PCT to guide cessation of antimicrobial therapy in patients with persistent IAA who exhibited clinical improvement.

Methods

A retrospective analysis of patients with IAA who had PCT levels available to review was performed in a tertiary academic teaching institution in the United States between 2017 and 2018. Demographics, clinical characteristics, and outcomes were obtained from the medical records. Patients were followed up for a minimum of 180 days after completion of antimicrobial therapy to determine if evidence of recurrence or mortality was present.

Results

We identified four patients with IAA. They underwent early drainage of the source of infection and received empiric antimicrobial therapy according to individual risk factors and clinical scenarios. Antimicrobials were discontinued after clinical and radiographic improvement and evidence of normal PCT levels, regardless of the persistence of fluid collections. No evidence of recurrence or mortality was observed during the follow-up period.

Conclusions

We found PCT to be a useful aid in the medical decision-making process to safely discontinue antimicrobial therapy in a series of patients with persistent intra-abdominal collections despite early drainage and appropriate course of antimicrobial therapy.

Prognostic factors of critical acute pancreatitis: A prospective cohort study

BACKGROUND

Patients with critical acute pancreatitis (CAP) have the highest risk of mortality. However, there have been no studies specifically designed to evaluate the prognostic factors of CAP.

AIMS & METHODS

This was a prospective observational cohort study involving patients with CAP. Three aspects including organ failure, (peri)pancreatic necrotic fluid cultures and surgical interventions were analyzed specifically to identify prognostic factors.

RESULTS

Of the 102 consecutive patients with CAP, 83 patients (81.4%) received step-up surgical treatment, the mortality of the step-up group was 25.3% (21/83). 19 patients (18.6%) underwent step-down surgical treatment, the mortality of the step-down group was 57.9% (11/19). Overall mortality in the whole cohort was 31.4% (32/102). Multivariate analysis of death predictors indicated that multiple organ failure (MOF) (OR = 5.3; 95% CI, 1.5-18.2; p = 0.008), long duration (≥5 days) of organ failure (OR = 6.4; 95% CI, 1.2-54.3; p = 0.029), multidrug-resistant organisms (MDROs) infection (OR = 4.6; 95% CI, 1.3-15.8; p = 0.013), OPN (OR = 3.7; 95% CI, 1.5-8.8; p = 0.004) and step-down surgical treatment (OR = 3.5; 95% CI, 1.2-10.1; p = 0.019) were significant factors.

CONCLUSION

Among patients with CAP, MOF, long duration (≥5 days) of organ failure, MDROs infection, OPN and step-down surgical treatment were identified as the predictors of mortality.

Ceftolozane/tazobactam for the treatment of complicated intra-abdominal and urinary tract infections: current perspectives and place in therapy

The current prevalence of infections caused by multidrug-resistant (MDR) organisms is a global threat, and thus, the development of new antimicrobial agents with activity against these pathogens is a healthcare priority. Ceftolozane-tazobactam (C/T) is a new combination of a cephalosporin with a β-lactamase inhibitor that shows excellent in vitro activity against a broad spectrum of Enterobacteriaceae and Pseudomonas aeruginosa, including extended spectrum β-lactamase-producing (ESBL) strains and MDR or extensively drug-resistant (XDR) P. aeruginosa. In phase III randomized clinical trials, C/T demonstrated similar efficacy to meropenem for the treatment of complicated intra-abdominal infections (cIAIs) and superior efficacy to levofloxacin for the treatment of complicated urinary tract infections (cUTIs), including pyelonephritis. The drug is generally safe and well tolerated and its PK/PD profile is very favorable. Observational studies with C/T have revealed good efficacy for the treatment of different types of infection caused by MDR or XDR P. aeruginosa, including some that originated from the digestive or urinary tracts. The place of C/T in therapy is not well defined, but its use could be recommended in a carbapenem-sparing approach for the treatment of infections caused by ESBL-producing strains or for the treatment of infections caused by P. aeruginosa if there are no other more favorable therapeutic options. Further clinical experience is needed to position this new antimicrobial drug for the empirical treatment of cIAIs or cUTIs.

Outcomes of infected pancreatic necrosis complicated with duodenal fistula in the era of minimally invasive techniques

Background: Duodenal fistula (DF) was reportedly thought to be the second most common type of gastrointestinal fistula secondary to acute necrotizing pancreatitis. However, infected pancreatic necrosis (IPN) associated DF (IPN-DF) was rarely specifically reported in the literature. The outcome of IPN-DF was also less well recognized, especially in the era of minimally invasive techniques. A retrospective cohort study was designed mainly focused on the management and outcomes of IPN-DF in the era of minimally invasive techniques. Methods: One hundred and twenty-one consecutive patients diagnosed with IPN between January 2015 and May 2018 were enrolled retrospectively. Among them, 10 patients developed DF. The step-up minimal invasive techniques were highlighted and outcomes were analyzed. Results: Compared with patients without IPN-DF, patients with IPN-DF had longer hospital stay (95.8 vs. 63.5 days, p < .01), but similar mortality rates (10% vs. 21.6%, p > .05). The median interval between the onset of acute pancreatitis (AP) and detection of DF was 2.4 months (1-4 months). The median duration of DF was 1.5 months (0.5-3 months). Out of the 10 patients with DF, 9 had their fistulas resolve spontaneously over time by means of controlling the source of infection with the use of minimally invasive techniques and providing enteral nutritional support, while one patient died of uncontrolled sepsis. No open surgery was performed. On follow-up, the 9 patients recovered completely and remained free of infection and leakage. Conclusion: IPN-DF could be managed successfully using minimally invasive techniques in specialized acute pancreatitis (AP) center. Patients with IPN-DF suffered from a longer hospital stay, but similar mortality rate compared with patients without DF.

Epidemiology and outcomes of source control procedures in critically ill patients with intra-abdominal infection

PURPOSE

To describe the characteristics and procedural outcomes of source control interventions among Intensive Care Unit (ICU) patients with severe intra-abdominal-infection (IAI).

MATERIAL AND METHODS

We identified consecutive patients with suspected IAI in whom a source control intervention had been performed in two tertiary ICUs in the Netherlands, and performed retrospective in-depth case reviews to evaluate procedure type, diagnostic yield, and adequacy of source control after 14 days.

RESULTS

A total of 785 procedures were observed among 353 patients, with initial interventions involving 266 (75%) surgical versus 87 (25%) percutaneous approaches. Surgical index procedures typically involved IAI of (presumed) gastrointestinal origin (72%), whereas percutaneous index procedures were mostly performed for infections of the biliary tract/pancreas (50%) or peritoneal cavity (33%). Overall, 178 (50%) patients required multiple interventions (median 3 (IQR 2-4)). In a subgroup of 236 patients having their first procedure upon ICU admission, effective source control was ultimately achieved for 159 (67%) subjects. Persistence of organ failure was associated with inadequacy of source control at day 14, whereas trends in inflammatory markers were non-predictive.

CONCLUSIONS

Approximately half of ICU patients with IAI require more than one intervention, yet successful source control is eventually achieved in a majority of cases.

Sepsis: The evolution in definition, pathophysiology, and management

There has been a significant evolution in the definition and management of sepsis over the last three decades. This is driven in part due to the advances made in our understanding of its pathophysiology. There is evidence to show that the manifestations of sepsis can no longer be attributed only to the infectious agent and the immune response it engenders, but also to significant alterations in coagulation, immunosuppression, and organ dysfunction. A revolutionary change in the way we manage sepsis has been the adoption of early goal-directed therapy. This involves the early identification of at-risk patients and prompt treatment with antibiotics, hemodynamic optimization, and appropriate supportive care. This has contributed significantly to the overall improved outcomes with sepsis. Investigation into clinically relevant biomarkers of sepsis are ongoing and have yet to yield effective results. Scoring systems such as the sequential organ failure assessment and Acute Physiology and Chronic Health Evaluation help risk-stratify patients with sepsis. Advances in precision medicine techniques and the development of targeted therapy directed at limiting the excesses of the inflammatory and coagulatory cascades offer potentially viable avenues for future research. This review summarizes the progress made in the diagnosis and management of sepsis over the past two decades and examines promising avenues for future research.

Sepsis management and the pediatric surgeon

Sepsis is a life-threatening condition that requires aggressive, timely, and multi-disciplinary care. Understanding the changes in national guidelines regarding definitions, diagnosis and the management of pediatric sepsis is critical for the pediatric surgeon participating in the care of these patients. The purpose of this article is to review the essential steps for the timely management of pediatric sepsis, including fluid resuscitation, antibiotics, vasopressors, and steroids. This includes a description of the key adjunct modalities of treatment, including renal replacement therapy and extracorporeal life support (ECLS).

Recognition and Management of Sepsis in the Obstetric Patient

Sepsis is one of the principal causes of maternal mortality in obstetrics. Physiologic changes that occur during pregnancy create a vulnerable environment, predisposing pregnant patients to the development of sepsis. Furthermore, these changes can mask sepsis indicators normally seen in the nonobstetric population, making it difficult to recognize and treat sepsis in a timely manner. The use of maternal-specific early warning tools for sepsis identification and knowledge of appropriate interventions and their effects on the mother and fetus can help clinicians obtain the best patient outcomes in acute care settings. This article outlines the signs and symptoms of sepsis in obstetric patients and discusses treatment options used in critical care settings.

Sepsis and septic shock

Sepsis is a common condition that is associated with unacceptably high mortality and, for many of those who survive, long-term morbidity. Increased awareness of the condition resulting from ongoing campaigns and the evidence arising from research in the past 10 years have increased understanding of this problem among clinicians and lay people, and have led to improved outcomes. The World Health Assembly and WHO made sepsis a global health priority in 2017 and have adopted a resolution to improve the prevention, diagnosis, and management of sepsis. In 2016, a new definition of sepsis (Sepsis-3) was developed. Sepsis is now defined as infection with organ dysfunction. This definition codifies organ dysfunction using the Sequential Organ Failure Assessment score. Ongoing research aims to improve definition of patient populations to allow for individualised management strategies matched to a patient's molecular and biochemical profile. The search continues for improved diagnostic techniques that can facilitate this aim, and for a pharmacological agent that can improve outcomes by modifying the disease process. While waiting for this goal to be achieved, improved basic care driven by education and quality-improvement programmes offers the best hope of increasing favourable outcomes.

Ceftolozane/tazobactam for the treatment of XDR Pseudomonas aeruginosa infections

PURPOSE

The aim of this study was to evaluate the effectiveness of ceftolozane/tazobactam (C/T) for treating extensively drug-resistant Pseudomonas aeruginosa (XDR-PA) infections, and to analyze whether high C/T dosing (2 g ceftolozane and 1 g tazobactam every 8 h) and infection source control have an impact on outcome.

METHODS

Retrospective study of all consecutive patients treated with C/T for XDR-PA infection at a tertiary referral hospital (November 2015-July 2017). Main clinical and microbiological variables were analyzed.

RESULTS

Thirty-eight patients were included. Median age was 59.5 years and Charlson Comorbidity Index was 3.5. Fourteen (36.8%) patients had respiratory tract infection, six (15.8%) soft tissue, and six (15.8%) urinary tract infection. Twenty-three (60.5%) received high-dose C/T and in 24 (63.2%) C/T was combined with other antibiotics. At completion of treatment, 33 (86.8%) patients showed clinical response. At 90 days of follow-up, 26 (68.4%) achieved clinical cure, and 12 (31.6%) had clinical failure because of persistent infection in one patient, death attributable to the XDR-PA infection in four, and clinical recurrence in seven. All-cause mortality was 5 (13.2%). Lower C/T MIC and adequate infection source control were the only variables significantly associated with clinical cure.

CONCLUSIONS

C/T should be considered for treating XDR-PA infections, with infection source control being an important factor to avoid failure and resistance.

Evaluation of a Short Course of Antimicrobial Therapy for Complicated Intra-Abdominal Infections in Critically Ill Surgical Patients

BACKGROUND

The optimal duration of antimicrobial therapy for treatment of complicated intra-abdominal infections (cIAI) in critically ill surgical patients is unknown. Recent evidence suggests that a short (four-day) course of therapy may be effective, however data in severely critically ill patients are limited.

PATIENTS AND METHODS

A single-center, retrospective, cohort study was conducted at a tertiary academic medical center. Adult patients admitted to the surgical intensive care unit (SICU) with cIAI between December 2011 and July 2015 were enrolled. Patients undergoing transplantation and those with less than 24 h in the SICU were excluded. Patients were divided into two groups, short (≤ 7 d) and long (> 7 d) antimicrobial therapy. The primary outcome was treatment failure, which was defined as a composite of recurrent cIAI, secondary extra-abdominal infection, and/or in-hospital mortality from any cause. Categorical and continuous data were analyzed with χ² and Mann-Whitney U tests, respectively. Binary logistic regression was performed to determine factors associated with treatment failure and mortality.

RESULTS

Of 1,679 patients screened, 240 were included, 103 in the short and 137 in the long group. Patients in the short and long groups received a median of 5 and 14 d of therapy, respectively (p < 0.001). Treatment failure occurred less frequently with a short duration of therapy (39% versus 63%, p < 0.001) and it occurred two days sooner after source control in patients receiving the shorter courses of antimicrobial therapy (short, median 6 d, interquartile range [IQR] 3-9; long, 8 d, IQR 6-14; p < 0.001). Logistic regression demonstrated that a long duration of therapy was associated with treatment failure (odds ratio [OR] 2.186, 95% confidence interval [CI] 1.251-3.820, p = 0.006), but not with mortality (OR 0.738, 95% CI 0.329-1.655, p = 0.461).

CONCLUSIONS

In critically ill surgical patients with cIAI, a short duration of antimicrobial therapy after source control resulted in similar outcomes to previously published studies, providing support for the safety of this approach in critically ill patients.

The recognition and management of sepsis and septic shock: a guide for non-intensivists

Sepsis is common, often fatal and requires rapid interventions to improve outcomes. While the optimal management of sepsis in the intensive care setting is the focus of extensive research interest, the mainstay of the recognition and initial management of sepsis will occur outside the intensive care setting. Therefore, it is key that institutions and clinicians remain well informed of the current updates in sepsis management and continue to use them to deliver appropriate and timely interventions to enhance patient survival. This review discusses the latest updates in sepsis care including the new consensus definition of sepsis, the outcome of the proCESS, ProMISe and ARISE trials of early goal directed therapy (EGDT), and the most recent guidelines from the Surviving Sepsis Campaign.

Does drainage of the peritoneal cavity have an impact on the postoperative course of community-acquired, secondary, lower gastrointestinal tract peritonitis?

BACKGROUND

In the surgical management of lower gastrointestinal tract peritonitis (LGTP), drainage of the peritoneal cavity is often recommended. The objective of the study was to evaluate the impact of drainage of the abdominal cavity during management of LGTP.

METHODS

From January 2009 to January 2012, patients undergoing surgery for LGTP were included. The study comprised 3 steps: (1) description of the overall population; (2) comparison of the "no drainage" and "drainage" groups; and (3) a propensity score-matched analysis. The primary end point was the major complications rate; secondary end points were the overall complication, risk factors for postoperative complications, and the length of hospital stay.

RESULTS

A total of 205 patients underwent surgery for LGTP. Characteristics of the peritoneum were noted on the surgical report in 141 cases (68%). Abdominal drainage was implemented in 118 patients (83%). After propensity score matching, there was no difference between drainage and no drainage groups in the major postoperative complications (34.7% vs 34.8%; P = .89).

CONCLUSIONS

Drainage of the abdominal cavity had no impact on postoperative abscess and reoperation rates. Standardization of drainage in this context is required.

Longer-Duration Antimicrobial Therapy Does Not Prevent Treatment Failure in High-Risk Patients with Complicated Intra-Abdominal Infections

BACKGROUND

Recent studies have suggested the length of treatment of intra-abdominal infections (IAIs) can be shortened without detrimental effects on patient outcomes. However, data from high-risk patient populations are lacking. We hypothesized that patients at high risk for treatment failure will benefit from a longer course of antimicrobial therapy.

METHODS

Patients enrolled in the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated retrospectively to identify risk factors associated with treatment failure, which was defined as the composite outcome of recurrent IAI, surgical site infection, or death. Variables were considered risk factors if there was a positive statistical association with treatment failure. Patients were then stratified according to the presence and number of these risk factors. Univariable analyses were performed using the Kruskal-Wallis, χ², and Fisher exact tests. Logistic regression controlling for risk factors and original randomization group, either a fixed four-day antimicrobial regimen (experimental) or a longer course based on clinical response (control), also was performed.

RESULTS

We identified corticosteroid use, Acute Physiology and Chronic Health Evaluation II score ≥5, hospital-acquired infection, or a colonic source of IAI as risk factors associated with treatment failure. Of the 517 patients enrolled, 263 (50.9%) had one or two risk factors and 16 (3.1%) had three or four risk factors. The rate of treatment failure rose as the number of risk factors increased. When controlling for randomization group, the presence and number of risk factors were independently associated with treatment failure, but the duration of antimicrobial therapy was not.

CONCLUSIONS

We were able to identify patients at high risk for treatment failure in the STOP-IT trial. Such patients did not benefit from a longer course of antibiotic administration. Further study is needed to determine the optimum duration of antimicrobial therapy in high-risk patients.

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.