Complicated intra-abdominal infections in Europe: preliminary data from the first three months of the CIAO Study

Novel Beta-Lactam/Beta-Lactamase Plus Metronidazole vs Carbapenem for Complicated Intra-abdominal Infections: A Meta-analysis of Randomized Controlled Trials

Background

Complicated intra-abdominal infections (cIAIs) remain a leading cause of death in surgical wards, in which antibiotic treatment is crucial. We aimed to compare the efficacy and safety of novel β-lactam/β-lactamase inhibitors (BL/BLIs) in combination with metronidazole and carbapenems in the treatment of cIAIs.

Methods

A comprehensive search of randomized controlled trials (RCTs) was performed using Medline, Embase, and Cochrane Library, which compared the efficacy and safety of novel BL/BLIs and carbapenems for the treatment of cIAIs.

Results

Six RCTs consisting of 2254 patients were included. The meta-analysis showed that novel BL/BLIs in combination with metronidazole had a lower clinical success rate (risk difference [RD], -0.05; 95% CI, -0.07 to -0.02; I ² = 0%) and a lower microbiological success rate (RD, -0.04; 95% CI, -0.08 to -0.00; I ² = 0%). No difference was found between the 2 groups in incidence of adverse events (RD, 0.02; 95% CI, -0.01 to 0.06; I ² = 0%), serious adverse events (SAEs; RD, 0.01; 95% CI, -0.02 to 0.03; I ² = 0%), or mortality (RD, 0.01; 95% CI, -0.00 to 0.02). However, ceftazidime/avibactam had a higher risk of vomiting (RD, 0.03; 95% CI, 0.01 to 0.05; I ² = 47%), and the ceftolozane/tazobactam subgroup showed a higher incidence of SAEs (RD, 0.12; 95% CI, 0.01 to 0.03).

Conclusions

The efficacy of novel BL/BLIs in combination with metronidazole was not as high as that of carbapenems. Although no significant differences were found with respect to overall adverse events, SAEs, or mortality, the novel BL/BLIs has a higher risk of vomiting. We still need to be cautious about the clinical application of a new anti-infective combination.

Trial registration

PROSPERO ID: 42020166061.

[New possibilities in antibacterial treatment of intra-abdominal infections caused by multiresistant microflora]

AIM

To determine the place of new drugs with activity against multidrug resistant strains of microorganisms in the treatment of complicated intraabdominal infections.

MATERIAL AND METHODS

The incidence and distribution of pathogens isolated from intra-abdominal specimens in patients with intra-abdominal infections are analyzed.

RESULTS

The current situation on the growth of resistant strains among pathogens causing intra-abdominal infections is rewied. New combined drugs for the treatment of multidrug resistant infections - ceftolozane/tazobactam and ceftazidim/avibactam plus metronidazole, has been suggested. Their potential role in empiric and targeted antibacterial treatment of complicated intraabdominal infections is defined.

CONCLUSION

Taking into consideration local monitoring data and risk factors of multi resistant strains Ceftolozane/tazobactam in combination with metronidazole can be used in empiric regime of treatment. Due to the high activity on carbapenem resistant strains of Klebsiella pneumonia and the lack of alternatives, it is advisable to use Ceftazidim/avibactam for the targeted therapy.

Polymicrobial Bacteremia Involving Klebsiella pneumoniae in Patients with Complicated Intra-Abdominal Infections: Frequency, Co-Pathogens, Risk Factors, and Clinical Outcomes

Background: Klebsiella pneumoniae has gained notoriety because of its high antibiotic resistance and mortality. We compared the clinical features and outcomes of polymicrobial bacteremia involving K. pneumoniae (PBKP). Patients and Methods: A retrospective observational study of patients with polymicrobial and monomicrobial bacteremia involving K. pneumoniae from January 2012 to December 2016 was performed. The expression of resistance and virulence genes of 27 strains was also compared by polymerase chain reaction (PCR). Results: Among the polymicrobial group, the most common accompanying micro-organism was Escherichia coli. No differences in the expression of resistance and virulence genes was found among the 27 strains collected from the group. The analysis of the outcomes revealed that the patients with PBKP were more likely to have recurrent blood stream infections (p = 0.038), longer intensive care unit (ICU) lengths of stay (p = 0.043), and a higher total hospitalization cost (p = 0.045). However, no substantial differences in mortality were found between the two groups. The multivariable analysis revealed that a longer hospital stay prior to the onset of bacteremia (>20 days) was an independent risk factor for PBKP (p = 0.034), and the Sequential Organ Failure Assessment (SOFA) score upon onset of infection (p = 0.013), the adequacy of source control (p < 0.001), and iron supplementation (p = 0.003) were identified as independent predictors of mortality in patients with KP bacteremia. Conclusions: The development of septic shock and the concomitant use of iron supplementation are associated with higher mortality in patients with KP bacteremia, and PBKP did not increase the mortality of these patients, possibly because of the ability of K. pneumoniae to obscure the effects of other bacteria. Thus, adequate source control is more important than high-dose antibiotic therapy and is linked to higher survival.

Challenges associated with bariatric surgery - a multi-center report

Introduction

Due to the constantly growing demand for surgical treatment of obesity, it is necessary to create new bariatric centers and further improve presently active ones.

Aim

To identify which stages of conducting peri-operative care and organizing a modern bariatric center currently pose the greatest challenge.

Material and methods

An anonymous survey was designed and distributed to bariatric surgeons. Our questionnaire was divided into three parts: demographic characteristics, difficulties associated with peri-operative care for bariatric patients (assessed on a scale of 1-5) and difficulties associated with organization or running of bariatric centers in which participants are currently working (assessed on a scale of 1-5).

Results

Overall, 70 surgeons and surgical residents from 17 surgical centers participated in our survey. The most difficult element of the pre-operative care was compliance with the recommendation to cease smoking (3.47 ±1.28). The most difficult obstacle during the postoperative care period was implementation of the enhanced recovery after surgery (ERAS) protocol (2.27 ±1.31). Funding for the bariatric treatment was obtained exclusively from the National Health Fund by 60 (85.7%) respondents working in 15 different bariatric centers (88.2%). Among elements of bariatric infrastructure access to operating theater equipment sized for morbidly obese patients was reported to be the most difficult (3.8 ±1.68).

Conclusions

Pre-operative recommendations including smoking, physical activity or weight loss, as well as introducing ERAS protocol based peri-operative care, are difficult to execute in bariatric departments. Future specialized bariatric centers should be included in the centralized register and equipped with specialized infrastructure for morbidly obese patients.

Value of early change of serum C reactive protein combined to modified Alvarado score in the diagnosis of acute appendicitis

Background

The aim of this study is to test the diagnostic value of baseline and early change of C-reactive protein (CRP) concentrations, evaluated separately or in combination with the modified Alvarado score (MAS), in patients with clinically suspected acute appendicitis.

Methods

This is a prospective observational study including all patients presenting to the emergency department with an equivocal diagnosis of acute appendicitis. After inclusion, clinical and demographic data are recorded and blood samples were taken at baseline and 3 h after for serum CRP measurements (3 h CRP). The MAS is also calculated for all patients. The ultimate diagnosis of appendicitis was based on the histologic findings of the excised appendix in operated patients and clinical follow-up in emergency department discharged patients. Diagnostic accuracy of admission CRP, early change of CRP 3 h CRP minus admission CRP, MAS and the combination of these parameters was expressed by sensitivity, specificity, positive predictive value, negative predictive value and area under receiver operating characteristics curve.

Results

Five hundred patients were included from January 2010 to December 2013. Overall, 387 patients were operated the negative appendectomy rate was 8,3%. CRP concentrations were higher in patients with acute appendicitis. However, the diagnostic value of admission CRP, delta CRP and MAS was moderate with area under ROC curve respectively equal to 0.63, 0.53 and 0.6. Combining admission CRP and delta CRP values to MAS did not result in a better performance. The area under ROC curve did not exceed 0.7 with the different combinations.

Conclusion

Early change of CRP has a moderate diagnostic value in patients with clinically suspected acute appendicitis. Combining CRP values to MAS did not improve diagnostic accuracy.

Molecular characteristics of extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae causing intra-abdominal infections from 9 tertiary hospitals in China

BACKGROUND

Recently, the emergence of multidrug-resistant organisms such as extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae has raised considerable concern regarding the appropriate treatment of intra-abdominal infections (IAIs). In this study, we investigated the molecular characteristics of ESBL among clinical isolates of Escherichia coli and Klebsiella pneumoniae causing IAIs and their pattern of antimicrobial resistance, which can provide useful information about the epidemiology and risk factors associated with these infections.

MATERIALS AND METHODS

One hundred sixty-seven E.coli and 47 K. pneumoniae ESBL-producing strains causing IAIs were collected from 9 hospitals in China, during 2012 and 2013. The antimicrobial susceptibility profile of these strains was determined. Polymerase chain reaction and sequencing were performed to identify genes for β-lactamase (blaTEM, blaSHV, blaOXA-1-like, and blaCTX-M). The isolates were also analyzed by pulsed-field gel electrophoresis (PFGE).

RESULTS

In 167 ESBL-producing E. coli strains, 104 strains (62.3%) were positive for CTX-M, and 9 strains (5.39%) were positive for SHV. Among the 47 K. pneumoniae strains, 35 strains (74.5%) were positive for SHV-2a, 12 strains (25.5%) were positive for CTX-M. No TEM-type and OXA-1-like strain was detected among all the ESBL-producing strains. Regarding the CTX-M-positive E. coli and K. pneumoniae strains, CTX-M-15 was the most common genotype in E. coli and K. pneumoniae strains, accounting for 28.7% and 17.0%, respectively, followed by CTX-M-55 accounting for 16.2% and 2.13%, respectively; the remaining genotypes included CTX-M-123 and CTX-M-82. PFGE showed that E.coli and K. pneumoniae ESBL-producing strains causing IAIs were diverse and that emerging resistance may not be due to the dissemination of national clones.

CONCLUSION

The present study revealed that in ESBL-producing strains causing IAIs in China, the most common genotype for E.coli was CTX-M-15 and for K. pneumoniae was SHV-2a. However, there was a wide diversity of strains causing IAIs among the ESBL-producing E. coli and K. pneumoniae.

Diagnostic Value of White Blood Cell and C-Reactive Protein in Pediatric Appendicitis. Biomed Res Int. 2016;2016:6508619. [PMID: 27274988 PMCID: PMC4870336 DOI: 10.1155/2016/6508619]

Background. Acute appendicitis (AA) associated with acute phase reaction is the most prevalent disease which requires emergency surgery. Its delayed diagnosis and unnecessarily performed appendectomies lead to numerous complications. In our study, we aimed to detect the role of WBC and CRP in the exclusion of acute and complicated appendicitis and diagnostic accuracy in pediatric age group. Methods. Appendectomized patient groups were constructed based on the results of histological evaluation. The area under a receiver operating characteristic (ROC) curve (AUC) was performed to examine diagnostic accuracy. Results. When WBC and CRP were used in combination, based on cut-off values of ≥13.1 × 10³/μL for WBC counts and ≥1.17 mg/dL for CRP level, diagnostic parameters were as follows: sensitivity, 98.7%; specificity, 71.3%; PPV, 50.6%; NPV, 99.5%; diagnostic accuracy, 77.6%; LR(+), 3.44; LR(−), 0.017. AUC values were 0.845 (95% CI 0.800–0.891) for WBC and 0.887 (95% CI 0.841–0.932) for CRP. Conclusions. For complicated appendicitis, CRP has the highest degree of diagnostic accuracy. The diagnosis of appendicitis should be made primarily based on clinical examination, and obviously more specific and systemic inflammatory markers are needed. Combined use of cut-off values of WBC (≥13100/μL) and CRP (≥1.17 mg/L) yields a higher sensitivity and NPV for the diagnosis of complicated appendicitis.

Morphology-Independent Virulence of Candida Species during Polymicrobial Intra-abdominal Infections with Staphylococcus aureus

Intra-abdominal polymicrobial infections cause significant morbidity and mortality. An experimental mouse model of Candida albicans-Staphylococcus aureus intra-abdominal infection (IAI) results in 100% mortality by 48 to 72 h postinoculation, while monomicrobial infections are avirulent. Mortality is associated with robust local and systemic inflammation without a requirement for C. albicans morphogenesis. However, the contribution of virulence factors coregulated during the yeast-to-hypha transition is unknown. This also raised the question of whether other Candida species that are unable to form hyphae are as virulent as C. albicans during polymicrobial IAI. Therefore, the purpose of this study was to evaluate the ability of non-albicans Candida (NAC) species with various morphologies and C. albicans transcription factor mutants (efg1/efg1 and cph1/cph1) to induce synergistic mortality and the accompanying inflammation. Results showed that S. aureus coinoculated with C. krusei or C. tropicalis was highly lethal, similar to C. albicans, while S. aureus-C. dubliniensis, S. aureus-C. parapsilosis, and S. aureus-C. glabrata coinoculations resulted in little to no mortality. Local and systemic interleukin-6 (IL-6) and prostaglandin E2 (PGE2) levels were significantly elevated during symptomatic and/or lethal coinfections, and hypothermia strongly correlated with mortality. Coinoculation with C. albicans strains deficient in the transcription factor Efg1 but not Cph1 reversed the lethal outcome. These results support previous findings and demonstrate that select Candida species, without reference to any morphological requirement, induce synergistic mortality, with IL-6 and PGE2 acting as key inflammatory factors. Mechanistically, signaling pathways controlled by Efg1 are critical for the ability of C. albicans to induce mortality from an intra-abdominal polymicrobial infection.

Role of damage control surgery in the treatment of Hinchey III and IV sigmoid diverticulitis: a tailored strategy

Many of the treatment strategies for sigmoid diverticulitis are actually focusing on nonoperative and minimally invasive approaches. The aim of this systematic review was to evaluate the actual role of damage control surgery (DCS) in the treatment of generalized peritonitis caused by perforated sigmoid diverticulitis.A literature search was performed in PubMed and Google Scholar for articles published from 1960 to July 2013. Comparative and noncomparative studies that included patients who underwent DCS for complicated diverticulitis were considered.Acute Physiology and Chronic Health Evaluation score, duration of open abdomen, intensive care unit length of stay, reoperation, bowel resection performed at first operation, fecal diversion, method, and timing of closure of abdominal wall were the main outcomes of interest.According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses algorithm for the literature search and review, 10 studies were included in this systematic review. DCS was exclusively performed in diverticulitis patients with septic shock or requiring vasopressors intraoperatively. Two surgical different approaches were highlighted: limited resection of the diseased colonic segment with or without stoma or reconstruction in situ, and laparoscopic washing and drainage without colonic resection.Despite the heterogeneity of patient groups, clinical settings, and interventions included in this review, DCS appears to be a promising strategy for the treatment of Hinchey III and IV diverticulitis, complicated by septic shock. A tailored approach to each patient seems to be appropriate.

Is laparoscopy a safe approach for diffuse appendicular peritonitis? Feasibility and determination of risk factors for post-operative intra-abdominal abscess

BACKGROUND

Several studies have assessed feasibility and early outcomes of the laparoscopic approach for complicated appendicitis (CA). However, these studies suffer from limitations due to the heterogeneous definitions used for CA. No studies have assessed feasibility and early post-operative outcomes of the laparoscopic approach in the specific management of diffuse appendicular peritonitis (DAP). Consequently, outcomes of the laparoscopic approach for the management of DAP are poorly documented.

METHODS

The laparoscopic approach is the first-line standardised procedure used by our team for the management of DAP. All patients (aged >16 years) who underwent laparoscopy for DAP (CA with the presence of purulent fluid with or without fibrin membranes in at least a hemi abdomen) between 2004 and 2012 were prospectively included. Post-operative outcomes were analysed according to the Clavien-Dindo classification.

RESULTS

Laparoscopy for DAP was performed for 141 patients. Mean age was 39.6 ± 20 (16-92) years. A total of 45 patients (31.9%) had pre-operative contracture. The mean pre-operative leukocyte count was 14,900 ± 4,380 mm(-3). The mean pre-operative C-reactive protein (CRP) serum concentration was 135 ± 112 (2-418) mg/dl. The conversion rate was 3.5%. The mean operative time was 80 ± 27 (20-180) min. There were no deaths. The rate of grade III morbidity was 6.5%. Ten patients (7.1%) experienced intra-abdominal abscess (IAA); seven of these cases were treated conservatively. The mean length of hospital stay was 6.9 ± 5 (2-36) days. A pre-operative leukocyte count >17,000 mm(-3), and CRP serum concentration >200 mg/dl were significant predictive factors for IAA in multivariate analyses [odds ratio (OR) 25.0, 95% confidence interval (CI) 2.4-250, p = 0.007 and OR 16.4, 95% CI 1.6-166, p = 0.02, respectively].

CONCLUSION

The laparoscopic approach for DAP is a safe and feasible procedure with a low conversion rate and an acceptable rate of IAA in view of the severity of the disease. Pre-operative leukocyte counts >17,000 mm(-3) and pre-operative CRP serum concentrations >200 mg/dl indicate a high risk of IAA.

2013 WSES guidelines for management of intra-abdominal infections

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

Correlation of serum C-reactive protein, white blood count and neutrophil percentage with histopathology findings in acute appendicitis

BACKGROUND

Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis of acute appendicitis is based on careful history, physical examination, laboratory and imaging investigation. The aim of the study is to analyze the role of C-reactive protein (CRP), white blood count (WBC) and Neutrophil percentage (NP) in improving the accuracy of diagnosis of acute appendicitis and to compare it with the intraoperative assessment and histopathology findings.

MATERIALS AND METHODS

This investigation was a prospective double blinded clinical study. The study was done on 173 patients surgically treated for acute appendicitis. The WBC, NP, and measurement of CRP were randomly collected pre-operatively from all involved patients. Macroscopic assessment was made from the operation. Appendectomy and a histopathology examination were performed on all patients. Gross description was compared with histopathology results and then correlated with CRP, WBC, and NP.

RESULTS

The observational accuracy was 87,3%, as compared to histopathological accuracy which was 85.5% with a total of 173 patients that were operated on. The histopathology showed 25 (14.5%) patients had normal appendices, and 148 (85.5%) patients had acutely inflamed, gangrenous, or perforated appendicitis. 52% were male and 48% were female, with the age ranging from 5 to 59 with a median of 19.7. The gangrenous type was the most frequent (52.6%). The WBC was altered in 77.5% of the cases, NP in 72.3%, and C-reactive protein in 76.9% cases. In those with positive appendicitis, the CRP and WBC values were elevated in 126 patients (72.8%), whereas NP was higher than 75% in 117 patients (67.6%). Out of 106 patients with triple positive tests, 101 (95.2%) had appendicitis. The sensitivity, specificity, and positive predictive values of the 3 tests in combination were 95.3%, 72.2%, and 95.3%, respectively.

CONCLUSION

The raised value of the CRP was directly related to the severity of inflammation (p-value <0.05). CRP monitoring enhances the diagnostic accuracy of acute appendicitis. The diagnostic accuracy of CRP is not significantly greater than WBC and NP. A combination of these three tests significantly increases the accuracy. We found that elevated serum CRP levels support the surgeon's clinical diagnosis.