Intra-abdominal Infections Research Articles

A phase 3 randomized trial of sulopenem vs. ertapenem in patients with complicated intraabdominal infections

ObjectiveTo demonstrate the noninferiority of intravenous (IV) sulopenem to IV ertapenem, each followed by an oral regimen, in adults with complicated intraabdominal infections (cIAI). MethodsHospitalized adults with cIAI were randomized to 5 days of IV sulopenem followed by oral sulopenem etzadroxil/probenecid twice daily or 5 days of IV ertapenem followed by oral ciprofloxacin/metronidazole or amoxicillin-clavulanate depending on baseline pathogen susceptibility. The target treatment duration was 7-10 days. The primary (FDA-specified) endpoint was clinical response at Day 28 [Test-of-Cure (TOC)] in the micro-Modified Intent to Treat (micro-MITT) population. Results674 patients were randomized. The two treatment arms were well-balanced. E. coli (395 patients) and B. fragilis (111 patients) were the most frequently isolated pathogens. Clinical success rates in the micro-MITT population were 81.9% (204/249) for sulopenem-treated patients and 87.9% (233/265) for ertapenem-treated patients. The lower bound of the confidence interval (CI) for the treatment difference of the primary endpoint was below the prespecified non-inferiority margin of -10.0 [treatment difference -6.0%, 95% CI [-12.2, 0.2]. In all other analysis populations, the lower limit of the 95% CI was above -10.0. Treatment emergent adverse events (all, 26.0% [87/335] vs 23.4% [78/333]; related, 6.0% [20/335] vs 5.1% [17/333]) were similar for sulopenem and ertapenem, respectively. Most events were mild to moderate in severity. There were more serious adverse events in the sulopenem arm (7.5% [25/335] vs 3.6% [12/333]), only two of which were considered possibly drug-related. ConclusionsSulopenem IV followed by oral sulopenem etzadroxil/probenecid was not noninferior to ertapenem followed by oral step-down in treating cIAI in the micro-MITT population. This finding should be interpreted in the context of country regulations, as endpoint timing, primary analysis population and noninferiority margin may vary regionally. Both IV and oral sulopenem were well-tolerated; the oral formulation allowed patients with resistant pathogens to step down from IV therapy. Clinical Trial RegistrationNCT03358576.

Positioning for Emergency Laparoscopic Splenectomy for Traumatic Splenic Rupture.

To determine whether the right-lateral decubitus or supine position is superior for emergency laparoscopy for traumatic splenic rupture. Descriptive study. Place and Duration of the Study: Department of General Surgery, Central Hospital of Shaoxing, Affiliated Hospital of China Medical University, Zhejiang, China, from January 2015 to December 2022. Clinical data of 96 patients who underwent laparoscopic surgery (LS) for traumatic splenic rupture were analysed. The patients were divided into two groups according to surgical position. Group A (n = 42) patients were placed in the right-lateral decubitus position and Group B (n = 54) patients were placed in the supine position. The operation time, intraoperative blood loss, conversion to laparotomy rate, postoperative length of hospital stay, and complications rates were compared between the two groups. Compared with Group B, Group A had a shorter operation time (145.5 ± 24.4 min vs. 169.0 ± 15.3 min, p = 0.0001), less intraoperative blood loss (75.3 ± 35.3 ml vs. 110.3 ± 50.6 ml, p = 0.0002), fewer conversions to laparotomy (2.4% vs. 16.7%, p = 0.023), fewer cases of postoperative pancreatic leakage (7.1% vs. 24.1%, p = 0.027), and fewer complications (23.8% vs. 53.7%, p = 0.003); all differences were significant. There was no statistically significant difference in the postoperative length of hospital stay, hospital cost, or rate of complications such as fever, postoperative abdominal infection, postoperative bleeding or venous thrombosis between the two groups. For patients with traumatic splenic rupture, the right-lateral decubitus position is best for LS. Laparoscopy, Traumatic splenic rupture, Splenectomy, Surgical position.

Bactericidal versus bacteriostatic antibacterials: clinical significance, differences and synergistic potential in clinical practice.

Antibacterial activity can be classified as either bactericidal or bacteriostatic, using methods such as the MBC/MIC ratio and time-kill curves. However, such categorization has proven challenging in clinical practice, as these definitions only apply under specific laboratory conditions, which may differ from clinical settings. Several factors, such as the specific bacteria or infectious medium, can affect the action of antibiotics, with many antibacterials exerting both activities. These definitions have also led to the belief that bactericidal antibacterials are superior to bacteriostatic, especially in more severe cases, such as endocarditis, neutropenia and bacteraemia. Additionally, current dogma dictates against the combination of bactericidal and bacteriostatic antibacterials in clinical practice, due to potential antagonism. This review aimed to assess the differences in antibacterial activity of bactericidal and bacteriostatic antibacterials based on in vitro and in vivo studies and examine their antagonistic or synergistic effects. Our findings show that specific bacteriostatic agents, such as linezolid and tigecycline, are clinically non-inferior to bactericidals in multiple infections, including pneumonia, intra-abdominal infections, and skin and soft tissue infections. Studies also support using several bacteriostatic agents as salvage therapies in severe infections, such as neutropenic fever and endocarditis. Additionally, not all combinations of bacteriostatic and bactericidal agents appear to be antagonistic, with many combinations, such as linezolid and rifampicin, already being used. The findings should be interpreted with caution, as most evidence is from observational studies and there is a need for randomized controlled trials to assess their effectiveness and combinations, especially within the context of rising antimicrobial resistance.

The multiple roles of macrophages in peritoneal adhesion

AbstractPeritoneal adhesion (PA) refers to the abnormal adhesion of the peritoneum either with the peritoneum itself or with tissues and organs that is caused by abdominopelvic surgery, abdominal infection or peritoneal inflammation. PA is associated with various clinical complications, such as abdominal pain and distension, intestinal obstruction, gastrointestinal disorders and female infertility, and adversely affects the quality of life of patients. Macrophages are essential for PA formation and can undergo polarization into classically activated macrophages (M1) and alternatively activated macrophages (M2), which are influenced by the peritoneal microenvironment. By releasing proinflammatory cytokines and reactive oxygen species, M1 macrophages promote peritoneal inflammatory reactions and the resultant formation of adhesion. In contrast, M2 macrophages secrete anti‐inflammatory cytokines and growth factors to inhibit PA formation and to promote repair and healing of peritoneal tissues, and thereby play a significant anti‐inflammatory role. This review comprehensively explores the function and mechanism of macrophages and their subtypes in PA formation to gain insight into the prevention and treatment of PA based on the modulation of macrophages.

Evaluation of preoperative blood markers for predicting intra-abdominal infection during colorectal cancer resection: A commentary on recent findings

Evaluation of preoperative blood markers for predicting intra-abdominal infection during colorectal cancer resection: A commentary on recent findings

Therapeutic drug monitoring (TDM) of β-lactam/β-lactamase inhibitor (BL/BLI) drug combinations: insights from a pharmacometric simulation study.

The emergence of β-lactamase-producing bacteria has led to the use of β-lactam (BL) antibiotic and β-lactamase inhibitor (BLI) drug combinations. Despite therapeutic drug monitoring (TDM) being endorsed for BLs, the impact of TDM on BLIs remains unclear. Evaluate whether BLIs are available in effective exposures at the site of infection and assess if TDM of BLIs could be of interest. Population pharmacokinetic models for 9 BL and BLI compounds were used to simulate drug concentrations at infection sites following EMA-approved dose regimens, considering plasma protein binding and tissue penetration. Predicted target site concentrations were used for probability of target attainment (PTA) analysis. Using EUCAST targets, satisfactory (≥90%) PTA was observed for BLs in patients with typical renal clearance (CrCL of 80 mL/min) across various sites of infection. However, results varied for BLIs. Avibactam achieved satisfactory PTA only in plasma, with reduced PTAs in abdomen (78%), lung (73%) and prostate (23%). Similarly, tazobactam resulted in unsatisfactory PTAs in intra-abdominal infections (79%), urinary tract infections (64%) and prostatitis (34%). Imipenem-relebactam and meropenem-vaborbactam achieved overall satisfactory PTAs, except in prostatitis and high-MIC infections for the latter combination. This study highlights the risk of solely relying on TDM of BLs, as this can indicate acceptable exposures of the BL while the BLI concentration, and consequently the combination, can result in suboptimal performance in terms of bacterial killing. Thus, dose adjustments also based on plasma concentration measurements of BLIs, in particular for avibactam and tazobactam, can be valuable in clinical practice to obtain effective exposures at the target site.

Validation of MEWS, NEWS, NEWS-2 and qSOFA for different infection foci at the emergency department, the acutelines cohort.

Sepsis is a leading cause of morbidity and mortality globally. The lack of specific prognostic markers necessitates tools for early risk identification in patients with suspected infections in emergency department (ED). This study evaluates the prognostic accuracy of various Early Warning Scores (EWS)-MEWS, NEWS, NEWS-2, and qSOFA-for in-hospital mortality, 30-day mortality, and ICU admission, considering the site of infection. A retrospective analysis was conducted using data from the Acutelines cohort, which included data collected from patients admitted to the University Medical Centre Groningen ED between September 2020 and July 2023. Patients were included if they had an ICD-10 code for infection. EWS were calculated using clinical data within 8h post-admission. Predictive performance was assessed using AUC-ROC, calibration by the Hosmer-Lemeshow test and calibration curves, and operative characteristics like sensitivity and specificity. A total of 1661 patients were analyzed, with infections distributed as follows: lower respiratory tract (32.9%), urinary tract (30.7%), abdominal (12.5%), skin and soft tissue (9.5%), and others (8.2%). The overall in-hospital mortality was 6.7%, and ICU admission was 7.1%. The highest AUC-ROC for in-hospital mortality prediction was observed with NEWS and NEWS-2 in abdominal infections (0.86), while the lowest was for qSOFA in skin and soft tissue infections (0.57). Predictive performance varied by infection site. The study highlights the variability in EWS performance based on infection site, emphasizing the need to consider the source of infection in EWS development for sepsis prognosis. Tailored or hybrid models may enhance predictive accuracy, balancing simplicity and specificity.

Gastrointestinal ultrasound in the critically ill: A narrative review and a proposal for a protocol.

Critically ill patients are at risk of presenting with gastrointestinal dysfunction at intensive care unit admission or during their stay. However, identifying gastrointestinal dysfunction is difficult because clinical evaluation is frequently nonspecific and validated biomarkers are lacking. In this context, ultrasound of the digestive tract may help to identify gastrointestinaldysfunction. In this narrative review, we summarize available evidence and propose a protocol for assessment of the gastrointestinal tract with ultrasound. First, we report available evidence from use of four available protocols: the gastrointestinal and urinary tract sonography protocol, the acute gastrointestinal injury ultrasound score, the transabdominal gastrointestinal ultrasoundprotocol, and the Lai protocol, each addressing somewhat different aspects. Outputs from these protocols have been associated with clinical scores of gastrointestinal failure, feeding intolerance, and 28-day mortality. Second, we describe the potential pitfalls of using ultrasound in the critically ill, such as obesity, abdominal dressings, or the presence of intraluminal gas. Third, we suggest perspectives of ultrasound in monitoring the response to enteral nutrition and for early identification of nonocclusive mesenteric ischemia. Fourth, we propose a structured protocol for gastrointestinal ultrasound describing all the different structures that should be evaluated and provide detailed guidance for a clockwise abdominal examination. In conclusion, the use of a specific and structured protocol might help to identify patients presenting with gastrointestinal dysfunction, guide nutrition, and allow the proposal of pathophysiological hypotheses (complications of enteral nutrition, intra-abdominal infection, bowel ischemia, etc.). The benefit of using a structured protocol requires further investigation.

Comparison of efficacy and safety between elacycline and polymyxin for complicated intra-abdominal infections caused by multidrug-resistant bacteria

Objective: To compare the efficacy and safety of eravacycline and polymyxin drugs in the treatment of multidrug-resistant complicated intra-abdominal infections(cIAI). Methods: The cIAI patients diagnosed or highly suspected of multidrug resistant bacterial infection who received eravacycline treatment at Sir Run Run Shaw Hospital and Shulan (Hangzhou) Hospital from June to August 2023 were prospectively included as the elacycline group. The cIAI patients with cIAI caused by multidrug resistant bacteria who received treatment with polymyxin (B or E) from January 2021 to August 2023 were retrospectively collected. The acute physiology and chronic health scores and age were matched with those of the elacrinid group, and they were included in the polymyxin group. The study mainly analyzed the clinical efficacy, microbial clearance rate, comprehensive efficacy, and safety of the two groups at the end of treatment and discharge. Results: A total of 72 patients with cIAI were included in the study, including 53 males and 19 females, aged (56.0±15.4) years. Among them, there were 28 cases in the eravacycline group and 44 cases in the polymyxin group. There was no statistically significant differences in the baseline, the proportion of patients who used combined drugs, the strains, the infection sites and infection conditions of patients between the two groups(all P>0.05).The clinical efficacy rate at the end of treatment [89.3% (25/28) vs 56.8%(25/44), P=0.004] and discharge [(88.5%(23/26) vs 63.6%,(28/44), P=0.024], microbial clearance rate at the end of treatment [(88.9% (24/27) vs 47.6%(20/42), P=0.001] and discharge [(91.3%(21/23) vs 59.5%(25/42), P=0.007], and overall recovery rate at the end of treatment [(89.3%(25/28) vs 52.3%(23/44), P=0.001] and discharge [(88.5%(23/26) vs 63.6%(28/44), P=0.024] in the erythromycin group were higher than those in the polymyxin drug group. In terms of safety, only 2 cases of mild vasculitis were observed in the eravacycline group. Conclusions: Combined regimens based on eravacycline showed better clinical effect in the treatment of cIAI caused by multidrug-resistant bacteria. The clinical effective rate, microbial clearance rate and comprehensive efficacy were significantly higher than those of polymyxin drugs at the end of treatment and discharge with good safety.

Effect of drugs of various groups on the pharmacokinetics of cefotaxime in comparison with their effect on lymphatic tissue drainage

Introduction. The lymphatic system plays a key role in spreading pathogens, including those causing intraabdominal infections. An urgent task of pharmacology is to create methods for the targeted delivery of antibiotics to lymphatic vessels and intestinal tissues. One approach is to use agents acting as endolymphatic conductors to achieve a high drug concentration in the lymphatic system. Aim. To evaluate the effect of various drugs on the concentration of cefotaxime, a third-generation antibiotic, in blood and intestinal tissues, as well as on lymphatic drainage in experiments on mice. Materials and methods. We investigated the effect of hyaluronidase (HLRD), bovgialuronidase azoximer (BovGLRD+Az), terrilitin (TRL), papaya milky juice (PMJ ), sodium heparin (HepS ), aprotinin (APRT), azoximer bromide (AzBrom), furosemide (FRSD) and sodium deoxyribonucleate (DRN) on the removal time of lymphotropic dye from mouse mesentery and the cefotaxime concentration in blood plasma and intestinal tissues by high-performance liquid chromatography. Results. HLRD reduced the time of dye removal from the mesentery by 26.2%, BovGLRD+Az – by 33.5%, TRL – by 36%, PMS – by 23.1%, HepS – by 30.1%, APRT – by 34.6%. The differences in lymphostimulating activity between these drugs were not statistically significant. AzBrom and FRSD increased the dye removal time by 8.3% and 6%, respectively; the DRN had no effect. HLRD, BovGLRD, TRL, PMJ, HepS and APRT increased the CF concentration in blood and intestinal tissues 1.5 and 24 hours after injection, in contrast to the single injection of antibiotic. AzBrom increased the CF concentration only after 1.5 hours. FRSD increased the antibiotic concentration in intestinal tissues but not in blood plasma. The DRN did not affect the studied indicators. Conclusion. Lymphostimulating drugs HLRD, BovGLRD, TRL, PMJ, HepS and APRT effectively direct the antibiotic to the lymphatic system and can be used for lymphotropic therapy.

Concentrations of ceftazidime and avibactam in bile fluid-a prospective phase IIb study.

The rise in carbapenem-resistant bacteria and the limited number of effective antibiotics pose a major health-care threat. The combination of ceftazidime (CAZ) and avibactam (AVI) represents an approved treatment option for carbapenem-resistant intra-abdominal infections. However, data on the pharmacokinetic profile of AVI in the hepatobiliary compartment is lacking. To provide clinical in vivo data on the concentration of AVI in bile fluid as a surrogate for hepatobiliary excretion. A single dose of 2000/500 mg CAZ/AVI was administered prolonged over 2 h to 10 patients prior to abdominal surgery, with bile samples available in nine patients in this phase IIb study (DRKS-ID: DRKS00023533). Antibiotic concentrations in plasma (0-8 h), bile (after resection) and pharmacodynamic parameters were determined. The mean concentration across individuals in bile was 33.5 mg/L (±20.5 mg/L) for CAZ and 7.1 mg/L (±3.5 mg/L) for AVI, resulting in bile/plasma ratios of 0.58 (±0.26) and 0.61 (±0.18). The Cmax in plasma was 87.2 mg/L (±25.0 mg/L) for CAZ and 18.6 mg/L (±6.29 mg/L) for AVI, with AUC0-∞ values of 351 h·mg/L (±104 h·mg/L) and 72.1 h·mg/L (±32.1 h·mg/L), respectively. Plasma concentrations of both CAZ and AVI remained more than 50% of the dosing interval above the minimum inhibitory concentrations (T>MIC > 50%; MICCAZ = 8 mg/L, MICAVI = 1 mg/L) in all patients. No antibiotic-associated side effects were reported during the 30-day follow-up. The concentrations of CAZ and AVI in bile suggest their potential as a valuable therapeutic option for multi-resistant biliary infections.

Gram-Negative Bacteremia: Epidemiology and Antimicrobial Resistance in Qatar

One of the major causes of morbidity and mortality in hospitalised patients is the presence of gram-negative bacteremia (GNB) in blood. The developed resistance among the bacteria poses a significant challenge for treatment. The study aimed to identify the gram-negative patient’s epidemiological risk factors, antimicrobial susceptibility patterns, and clinical outcomes. A retrospective observational study of adult in-patients with gram-negative bacteremia was conducted between January 2019 and December 2020 in the 320-bed general hospital in Qatar. Data on demographics, antimicrobial resistance, source of infection, and treatment were collected. The primary outcomes were patients’ cure, death, or relapse. Total of 357 patients were identified with bacteremia, the most common sources being urinary tract infections (39.6%), intra-abdominal infections (28%), and lower respiratory tract infections (9%). The mean duration of the intravenous and oral antibiotics administration was 14 days. Surgical source control was performed in 35.7% of patients. Common pathogens were Escherichia-coli (47.2%), Klebsiella pneumoniae (16.4%), Salmonella enterica serotype Typhi (10.6%), and Pseudomonas aeruginosa (7.8%). 67.32% fully susceptible strains, 31.56% extended-spectrum beta-lactamase (ESBL) producing bacteria, and 1.11% multidrug-resistant organisms (MDROs) were among the isolates. Most infections (68%) were cured, but 5% had recurrence within 90 days of admission. Infection-related mortality was 8%, and death due to non-infectious causes was 2%. In conclusion, Gram-negative BSIs are severe infections with increasing antimicrobial resistance, primarily caused by ESBL-producing bacteria. High mortality rates are linked to diabetes, age, and hospitalisation, necessitating antibiotic treatment optimisation.

7491 Post operative Euglycemic Diabetic Ketoacidosis in Type 2 Diabetic patient - A diagnostic challenge

Abstract Disclosure: S. Azmat: None. O. Lodhi: None. H. Ashok: None. M.F. Siddiqui: None. Euglycemic Diabetic Ketoacidosis (EDKA) is a rare but potentially fatal condition that is often difficult to diagnose as underlying ketoacidosis is masked by euglycemia. The diagnosis and management of this condition requires a swift and comprehensive approach to avoid delay. We report a case of 66-year-old female with Insulin-dependent Type 2 DM who developed postoperative euglycemic diabetic ketoacidosis, highlighting the significance of maintaining a high degree of suspicion for EDKA in postoperative patients, whose surgical course may obscure the underlying diabetic ketoacidosis symptoms. Clinical Case: A 66-year-old female with past medical history of Insulin dependent Type 2 DM presented to the emergency department with severe epigastric pain. CT Abdomen revealed perforated gastric ulcer with pneumoperitoneum requiring urgent laparoscopic graham patch repair. Patient’s outpatient medications include Lantus and metformin. She had mild hyperglycemia on admission with blood glucose of 176 mg/dL (140-160mg/dL) without metabolic abnormality. Insulin administration was omitted due to pre and post operative normoglycemia. The patient was NPO followed by initiation of nasogastric tube feeds. Postoperative course was complicated by hypotension, generalized abdominal discomfort and anion gap metabolic acidosis. Graham patch failure, abdominal infection, and post-surgical complications were systematically ruled out. Patient continued to decline with worsening anion gap metabolic acidosis; pH of 7.18 (7.35-7.45), HCO3 < 10 mEq/L (21 mEq/L - 31 mEq/L), anion gap15 mmol/L (8 to 12 mmol/L), blood sugar (147-208 mg/dl). There was no lactic acidosis or renal impairment. Beta hydroxybutyrate levels were elevated at > 4.5 mmol/L. Thus diagnosis of euglycemic DKA was established and treated with insulin drip per DKA protocol and dextrose fluids. EDKA resolved within five days with clinical improvement. She was transitioned to subcutaneous basal bolus insulin. She remained euglycemic and and had good surgical outcomes.Discussion: Euglycemic DKA is rare with only 2.6% to 3.2% of DKA, presenting as euglycemic. It presents as unique diagnostic challenge due to atypical DKA presentation with blood glucose less than 250 mg/dL. The primary driver for EDKA is either a reduction in hepatic glucose production at times of fasting or the overabundance of counter-regulatory hormones resulting in excess glucosuria. Literature has reported the effects short-term fasting on developing EDKA and starvation induced ketosis secondary to extreme ketogenic diets or bariatric surgery primarily among Type 1 diabetics. Clinically patients may exhibit symptoms similar to classic DKA, however, this classic picture may be confounded in a critically ill post-surgical patient, thus delaying recognition. This emphasizes the importance of including EDKA in differentials while evaluating such patients. Presentation: 6/1/2024

Clinical Effects of Laparoscopic Surgery in Radical Surgery for Colorectal Cancer

Objective: To investigate the clinical application effect of laparoscopic surgery in radical surgery for colorectal cancer. Methods: 78 patients who were treated with radical surgery for colorectal cancer in a tertiary hospital during the period from January 2021 to December 2023 were selected as the study subjects in this study. According to the different surgical methods, the patients were divided into the laparoscopic surgery group (40 cases in the experimental group) and the traditional open surgery group (38 cases in the control group). The operation time, intraoperative bleeding, postoperative recovery (including postoperative anal exhaustion time, time to get out of bed, and hospitalization time), complication rate, and therapeutic effect were observed in the two groups. Results: Patients in the experimental group were better than the control group in terms of intraoperative blood loss, operation time, postoperative anal exhaust time, time to get out of bed, and postoperative hospitalization time (P < 0.05). Patients in the experimental group had significantly better treatment effects and complication rates than those in the control group (P < 0.05). Conclusion: Compared with the open group, the overall prognosis of laparoscopic colorectal cancer patients is better, and laparoscopy has a protective effect on tumor recurrence or metastasis after radical surgery for colorectal cancer, and it can reduce the incidence of postoperative abdominal infection.

Skeletal muscle density as a new predictor of abdominal infection in abdominal trauma patients

Background and aimsSkeletal muscle density (SMD) is a valuable prognostic indicator in various conditions such as cancer, liver cirrhosis. Yet, the connection between SMD and intra-abdominal infection in individuals who have suffered abdominal injuries is still unclear. The purpose of this research is to examine how well SMD can predict intra-abdominal infection in patients who have suffered abdominal trauma. MethodsParticipants with abdominal injuries were included in this research from January 2015 to April 2023. Based on the sex-specific cut off values of SMD, the entire population was split into two categories. Prognostic factors were identified through logistic regression analysis. ROC was used to assess the predictive accuracy of SMD and its combinations with other biomarkers for clinical outcomes. ResultsA total of 220 patients were ultimately included in the study. Patients in the group with low SMD exhibited a higher incidence of intra-abdominal infection, longer hospital stays, and increased hospital costs. In patients with abdominal trauma, low SMD was identified as a significant independent predictor of intra-abdominal infection (OR 2.397; 95% CI 1.117- 5.141, p = 0.025). Low SMD had a higher area under the curve (AUC) in ROC analysis compared to TRF, NRS2002 score, and APACHEII score for predicting intra-abdominal infection (AUC 0.70, 95% CI 0.61-0.78, p = 0.002). Moreover, low SMD showed associations with clinical outcomes such as hospital stay length and costs (p < 0.01). ConclusionsLow SMD is recognized as an independent risk factor for predicting intra-abdominal infections in this patient population. Notably, SMD is emerging as a novel predictor of abdominal infections in patients with abdominal trauma.

Prophylactic intra-abdominal drainage during pancreaticoduodenectomy: A systematic review and meta-analysis

Background: Prophylactic abdominal drainage during pancreaticoduodenectomy (PD) is a common treatment strategy for pancreatic fistula. However, its benefits and safety have been the subject of debate. The objective of this meta-analysis and system review is to assess the effects of prophylactic drainage, various types of drainage (active and passive), and the timing of drainage removal (early and late) on the postoperative outcomes of PD. Methods: A systematic literature search was conducted in the PubMed, Web of Science, and Cochrane Library databases as of April 28, 2024. Randomized controlled trials (RCTs) comparing prophylactic abdominal drainage, different drainage patterns, and the timing of drainage removal after PD were included, and the postoperative outcomes were evaluated. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated to aggregate dichotomous outcomes. Meta-analysis was performed using the Mantel-Haenszel fixed- and random-effects models. Results: Nine RCTs, including a total of 1638 patients, were incorporated in our study. The meta-analysis showed no statistically significant differences in postoperative outcomes between the closed-suction drain (CSD) group and the passive drain to gravity (PDG) group. Compared to the late drain removal (LDR) group, the early drain removal (EDR) group had a significant reduction in the incidence of Clinically relevant postoperative pancreatic fistula (CR-POPF) (OR=0.39, 95% CI=0.20 to 0.79; P=0.009), morbidity (OR=0.41, 95% CI=0.20 to 0.84; P=0.01) and intra-abdominal infection (OR=0.40, 95% CI=0.22 to 0.75; P=0.004). For the group of present of drainage and the group of absent of drainage, the patient inclusion criteria of the included studies were too heterogeneous, making meta-analysis inappropriate. Conclusion: The existing evidence is insufficient to negate the necessity of prophylactic drainage after PD. The meta-analysis did not show superiority of any specific approaches of drainage tube. But this review did indicate that patients benefit from EDR in terms of CR-POPF, morbidity and intra-abdominal infection. EDR was recommended for low/intermediate risk patients.

Clinical application of inferior pancreaticoduodenal artery management in laparoscopic pancreaticoduodenectomy

Objective: To investigate the clinical effect of proper management of inferior pancreaticoduodenal artery (IPDA) in laparoscopic pancreaticoduodenectomy (LPD). Methods: This is a retrospective case series study. The clinical and pathological data of 70 patients who received LPD due to pancreatic head tumors, periampullary tumors, or distal common bile duct tumors in the Pancreatic Center of the Second Clinical College of Guangzhou University of Chinese Medicine from January to December 2022 were retrospectively collected. There were 47 males(67.1%) and 23 females(32.9%),aged (59.9±12.8)years(range:13 to 87 years).The procedure of IPDA exposure was as follows:a middle approach was utilized to expose the right half of superior mesenteric artery(SMA) and its right branches between the SMA and superior mesenteric vein(SMV) in superior colonic region. In the subcolonic region,SMA trunk exposure via dissection along the jejunal artery from feet to head and identification the association between IPDA and jejunal artery were prior to IPDA root ligation and dissection. The safety and efficacy of intraoperative IPDA handling were assessed based on surgical videos. Follow-up was carried out in outpatient clinic or by telephone, and outpatient follow-up was conducted once every 1 to 3 months after surgery. Results: The percentage of total LPD was 98.6%(69/70),with all patients achieving R0 resection. Nine cases(12.9%) were involved in combined vascular resection and reconstruction,with 1 case (1.4%) requiring additional upper abdominal incision for vascular and gastrointestinal reconstruction,while the remaining eight cases (11.4%) were completed laparoscopically. The operative time was (432.7±115.4)minutes(range:282 to 727 minutes), and the blood loss was (140.0±125.7)ml(range:20 to 800 ml). Only two patients(2.9%) received fresh frozen plasma transfusion,with an average volume of 650 ml. Reliable ligation and safe handling of the IPDA were achieved in 91.4%(64/70) of cases, with 8.6%(6/70) suffering from IPDA injury-related bleeding. No one was converted to opened surgery. Pathologically,the mean tumor size was (3.3±1.6)cm (range:1 to 7 cm),and the mean number of harvested lymph nodes was 17.0±7.3(range:0 to 46). Lymph node metastasis was observed in 13 cases (18.6%). Five cases (13.2%) developed grade B pancreatic fistula,while no grade C pancreatic fistula occurred. Other complications included bile leakage in one case(1.4%),delayed gastric emptying in two cases(2.9%), lymphatic leakage in 2 cases(2.9%),intra-abdominal infection in 9 cases(12.9%),and fat liquefaction of surgical incision in 1 case(1.4%). Two cases(2.9%) experienced postoperative intra-abdominal bleeding,one due to mesangial bleeding of lesser curvature of the stomach and the other due to oozing from the hepatic arterial sheath. These bleeding events were not concerned with IPDA. The average length of postoperative hospital stay was (15.2±4.6)days(range:9 to 28 days). Conclusion: Proper intraoperative management of IPDA in LPD might reduce IPDA-related bleeding during and after surgery and improve the safety of LPD.

Key Aspects of Pediatric Liver Transplant Patient Visits to the Pediatric Emergency Department.

Patients with liver transplant can present to a pediatric emergency department with short- and long-term complications of transplant. Here, we described clinical features of pediatric liver transplant patients admitted to the pediatric emergency department and identified risk factors that may lead to pediatric intensive care unit admission. We retrospectively evaluated pediatric liver transplant patients admitted posttransplant to Baskent University Hospital's pediatric emergency department in 2023. We noted symptoms, laboratory tests, hospitalization status, and final diagnoses. We compared clinical and laboratory features of patients admitted or not admitted to the intensive care unit. In 2023, 108 presentations of 33 liver transplant patients presented to our pediatric emergency department: 46.3% were girls, mean age was 7.79 ± 4.40 years, and median posttransplant day at time of emergency department visit was 622 days. Common symptoms were vomiting (48%), fever (46%), and rhinorrhea and cough (34%). Forty-nine visits (45.4%) resulted in hospitalization; 5 visits (4.6%) resulted in PICU admission, with 2 mortalities (1.8%). Final diagnoses included acute gastroenteritis and upper respiratory tract infections (23 patients) and lower respiratory tract infections (13 patients). Seven patients had cholangitis, 6 had intra-abdominal infection, and 5 had sepsis. Seizures and sepsis were significantly correlated with intensive care unit admission (P <.001). Patients admitted to the intensive care unit had significantly shorter time posttransplant versus other patients (518 ± 324 vs 1498 ± 1658 days; P < .001). Half of patients who presented to the emergency department required hospitalization mainly for observation and supportive treatment, with a small number requiring intensive care unit admission. Nevertheless, physicians caring for liver transplant patients should be aware of serious complications and monitor patients closely, especially early posttransplant when intensive immunosuppressive treatment regimens are used.

An Eleven-Year Retrospective Survey of Anaerobic Bloodstream Infection in Adults in a General Hospital.

During conditions accompanied by the disruption of normal mucosal barriers, anaerobic bacteria, which a part of normal human mucosal microflora, may cause various infections. In this study, clinical features of anaerobic bloodstream infections (BSI) in a general hospital in China were investigated. Patients with anaerobic BSI were retrospectively enrolled between 2012 and 2022. Demographic data, clinical manifestations, antibiotic treatments, and disease outcomes were analyzed. In total, 391 anaerobic bacterial strains were isolated from 381 patients aged older than 11 years of age. Given that medical records of 47 patients were missing, 334 patients were included in the clinical investigation. Patients with anaerobic BSI included in the study were predominantly older than 50 years of age. Intra-abdominal infections were the most common source of anaerobic BSI (59%), followed by those of the female genital tract (10.2%) and lower respiratory tract (7.2%). Among the isolates, Bacteroides and Clostridium spp. were the most frequently isolated anaerobes. Most of the patients received antibiotic therapy. The crude mortality was 4.5%. The detection rate of anaerobic BSI in Ningxia, China, remained relatively stable from 2012 to 2022. These results provide a reference for the diagnosis and empirical treatment of anaerobic BSI in this region of China. Continuous mul-ticenter studies should be conducted to monitor the incidence of anaerobic BSI and drug resistance of anaerobic isolates to improve the treatment outcomes of patients.

Nosocomial cluster of patients infected with imipenemase-1-producing Enterobacter ludwigii.

Introduction. Imipenemase (IMI) enzymes are an uncommon class A carbapenemases that have been isolated from aquatic environments and, occasionally, from clinical isolates of Enterobacterales.Aim. We describe a cluster of three patients infected by IMI-1 carbapenemase-producing Enterobacter ludwigii (IMI-1-Elud) in a tertiary university hospital in Gran Canaria, Spain.Methodology. Antimicrobial susceptibility was determined using the Vitek2 AST-N355 card and antibiotic gradient strips. The modified carbapenem inactivation method (CIM) test was performed in cases where the ertapenem MIC value was higher than 0.125 mg l-1. The carbapenemase was identified by PCR and DNA microarray and later characterized by whole-genome next-generation sequencing (NGS) with Illumina.Results. Three patients presented thoracic or abdominal infections caused by IMI-1-Elud ST1677 from 14 June 2022 to 14 July 2022. All patients underwent at least one gastroscopy during their admission, and two of them were located in adjoining rooms. Isolates were resistant to carbapenems, colistin and fosfomycin but susceptible to ciprofloxacin. IMI/NMC-A carbapenemase was detected by PCR and hybridization test and confirmed by NGS as IMI-1. All patients underwent at least one gastroscopy, and two of them were in nearby rooms. Patients showed microbiological and clinical improvement following focus drainage and targeted antibiotic treatment with a fluoroquinolone.Conclusions. This study reports the first documented global outbreak of patients infected with IMI-1-Elud. The source appeared to be related to endoscopes. Contact transmission may also have played a role. A screening method such as the modified CIM test is crucial for detecting less common carbapenemases that might not be identified by rapid molecular or immunochromatographic tests, as these often do not include bla IMI genes, which could lead to the undetected dissemination of carbapenemase-producing Enterobacterales. Effective infection source control and targeted treatment are essential for achieving a favourable clinical outcome.