Management Of Complicated Intra-abdominal Infections Research Articles

375: ANTIFUNGAL USE IN CRITICALLY ILL PATIENTS WITH INTRA-ABDOMINAL INFECTION

Introduction: Intra-abdominal infections arise from microorganisms which translocate from their normal location and result in peritoneal inflammation. Initiation of antifungal treatment for complicated intra-abdominal infections has limited clinical evidence and remains unclear. In 2010, the IDSA and SIS released a joint guideline regarding diagnosis and management of complicated intra-abdominal infections (IAIs). However in the following years, the two entities released their own individual guidelines. The goal of this study is to further delineate if there is a potential benefit for use of empiric antifungal therapy in critically ill patients with an IAI. Methods: This is a retrospective chart review study that screened hospitalized adult patients admitted to the intensive care units (ICU) with proven or suspected intra-abdominal infection and associated ICD-10 code between January 2020 to December 2021. Medical charts were reviewed for relevant demographic, clinical, and laboratory data. The primary endpoint is hospital length of stay (LOS). Secondary outcomes include ICU LOS, source of infection, surgical intervention, and mortality. A sub-group analysis comparing azole and echinocandin treatment was conducted; endpoints include hospital LOS, ICU LOS, source of infection, surgical intervention, antifungal duration, mortality, and rate of discharge on antifungal therapy. Results: From January 2020 – December 2021, 1086 patients were screened for eligibility and 166 patients were enrolled. The sample size was primarily male (53.4%) and Hispanic (36.1%) or Asian (28.9%). In this study, statistical significance was found for LOS (p< 0.0001), ICU LOS (p< 0.0001), surgical intervention (p< 0.0001) and peritoneum as source of infection (p=0.0006). In the sub-group analysis, statistical significance was found with surgical intervention (p< 0.0001), hospital LOS (p< 0.0001) and ICU LOS (p< 0.0001) in the micafungin treatment arm. Conclusions: In this study, use of antifungal treatment in critically ill patients decreased hospital LOS, ICU LOS, and surgical intervention. Patients on antifungal treatment may have had a higher severity of IAIs. There is an ongoing need for better characterization of patients at risk for poor prognosis.

THE MICROBIAL PATTERN OF COMPLICATED INTRA-ABDOMINAL INFECTIONS COMMUNITY IN H. ADAM MALIK GENERAL HOSPITAL MEDAN

Introduction: The principles management of complicated intra-abdominal infections are source control and antibiotic therapy. The main problem in its implementation is the slow handling time and inadequate antibiotic therapy, which leads in an increase in mortality in complicated intra-abdominal infections. Early empirical antibiotics are based on the pathological location and community microbial pattern. This study is aimed to evaluate microbial pattern at H. Adam Malik General Hospital between January 2017 and October 2019. Methods: This is a retro-prospective observational descriptive study. Results: There were 37 patients who met the inclusion criteria. The most common microbial pattern in this study was gramnegative bacteria, which was 62.1%. The most common gram-negative bacteria found were E.coli (32.4%), followed by Klebsiella pneumonia (24.3%). While the most common gram-positive bacteria found was Staphylococcus haemolyticus (8.1%). Conclusion: The most common microbial pattern found in this study was gram-negative bacteria, where the most common gram-negative bacteria was E. coli. The most common gram-positive bacteria was Staphylococcus haemolyticus

The impact of age and comorbidity on the postoperative outcomes after emergency surgical management of complicated intra-abdominal infections

Age-adjusted Charlson Comorbidity Index (a-CCI) score has been used to weight comorbid conditions in predicting adverse outcomes. A retrospective cohort study on adult patients diagnosed with complicated intra-abdominal infections (cIAI) requiring emergency surgery was conducted in order to elucidate the role of age and comorbidity in this scenario. Two main outcomes were evaluated: 90-day severe postoperative complications (grade ≥ 3 of Dindo-Clavien Classification), and 90-day all-cause mortality. 358 patients were analyzed. a-CCI score for each patient was calculated and then divided in two comorbid categories whether they were ≤ or > to percentile 75 ( = 4): Grade-A (0–4) and Grade-B ( ≥ 5). Univariate and multivariate regression analyses were performed, and the predictive validity of the models was evaluated by the area under the receiver operating characteristics (AUROC) curve. Independent predictors of 90-day severe postoperative complications were Charlson Grade-B (Odds Ratio [OR] = 3.49, 95% confidence interval [95%CI]: 1.86–6.52; p < 0.0001), healthcare-related infections (OR = 7.84, 95%CI: 3.99–15.39; p < 0.0001), diffuse peritonitis (OR = 2.64, 95%CI: 1.45–4.80; p < 0.01), and delay of surgery > 24 hours (OR = 2.28, 95%CI: 1.18–4.68; p < 0.02). The AUROC was 0.815 (95%CI: 0.758–0.872). Independent predictors of 90-day mortality were Charlson Grade-B (OR = 8.30, 95%CI: 3.58–19.21; p < 0.0001), healthcare-related infections (OR = 6.38, 95%CI: 2.72–14.95; p < 0.0001), sepsis status (OR = 3.98, 95%CI: 1.04–15.21; p < 0.04) and diffuse peritonitis (OR = 3.06, 95%CI: 1.29–7.27; p < 0.01). The AUROC for mortality was 0.887 (95%CI: 0.83–0.93). Post-hoc sensitivity analyses confirmed that the degree of comorbidity, estimated by using an age-adjusted score, has a critical impact on the postoperative course following emergency surgery for cIAI. Early assessment and management of patient’s comorbidity is mandatory at emergency setting.

New antimicrobial options for the management of complicated intra-abdominal infections.

Complicated intra-abdominal infections (cIAIs) are a common cause of morbidity and mortality in surgical patients. Optimal management of cIAI requires early source control in combination with adequate antimicrobial treatment and aggressive fluid resuscitation. cIAIs are mainly caused by Gram-negative bacilli and anaerobes. Broad-spectrum single-agent or combination drug regimens against these microorganisms are the mainstay of therapy. However, development of antimicrobial resistance has become an increasingly large concern: multidrug-resistant organisms are associated with a higher rate of inadequate antimicrobial therapy, which in turn is associated with higher mortality rate, longer hospital stay, and increased cost compared to adequate antimicrobial therapy. In this mini-review, we discuss the effectiveness of several new antimicrobial agents, recently approved or in advanced phases of clinical development, for the treatment of cIAIs, including the new beta-lactam and beta-lactamase inhibitor combinations (ceftolozane/tazobactam, ceftazidime/avibactam, meropenem/vaborbactam, imipenem/cilastatin/relebactam, aztreonam/avibactam), siderophore cephalosporins (cefiderocol), aminoglycosides (plazomicin), and tetracyclines (eravacycline).

Factor inluencing outcome of source control in the management of complicated intra-abdominal infection in Cipto Mangunkusumo University Hospital

Background: Source control (SC) procedure aiming to control the morbidity and mortality is essential in managing complicated intra-abdominal infection (cIAI). This study aims to review factors influencing the outcome of SC in cIAI cases at Cipto Mangunkusumo Hospital. Methods: CIAI patients undergoing SC procedure in 2017 in our hospital were retrospectively reviewed. Prevalence, etiology, demography, types of procedure, and outcomes were the variables subjected to analysis. Results: There were 110 (11.7%) cIAI cases of 945 abdominal surgeries, comprised of 74 (67.3%) males and 36 (32.7%) females. Median age was 43.9 years, including 24.5% participants aged >60 years. The most common etiology of mortality in cIAI was postoperative infection (POI) (36.4%), and the most frequently affected organ was lower gastrointestinal tract (GIT) (23.6%), especially colon which contributed to high mortality rates (34.6%). Operative mortality in participants who underwent drainage and debridement was 36% and 16.5%. Klebsiella pneumonia (36%) and Candida spp. (28.6%) infections were found in patients with poor outcome. Overall mortality was 20.9%. Conclusions: High rates of operative mortality commonly happened in emergency cases, relaparotomy, and cases treated with definitive procedure. Lower GIT cases had the highest frequency of cIAI. POI was the most common indication of SC procedure. Candida spp. and Klebsiella pneumonia infections were the most frequent organisms found with poor outcome. SC surgery was performed in all cIAIs.

Management of Complicated Intra-abdominal Infection: Our Experience

Management of Complicated Intra-abdominal Infection: Our Experience

Use of intravenous tigecycline in patients with severe Clostridium difficile infection: a retrospective observational cohort study

There are only a limited number of antimicrobials for treating severe Clostridium difficile infection (sCDI). Tigecycline shows significant in vitro effect against C. difficile and is approved for management of complicated intra-abdominal infections. Our aim was to analyse the efficacy of tigecycline compared with standard therapy (oral vancomycin plus intravenous metronidazole) in adults treated for sCDI. A retrospective cohort study of such patients hospitalized at our department from January 2014 to December 2015 was performed. Patients receiving tigecycline monotherapy were compared with patients treated with standard therapy alone. Diagnosis and severity of CDI were determined according to guidelines of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). Primary outcome was clinical recovery, secondary outcomes were in-hospital and 90-day all-cause mortality and relapse, colectomy, and complication rates. Of the 359 patients hospitalized for sCDI, 90 (25.0%) were included, 45 in each group. Patients treated with tigecycline had significantly better outcomes of clinical cure (34/45, 75.6% vs. 24/45, 53.3%; p 0.02), less complicated disease course (13/45, 28.9% vs. 24/45, 53.3%; p 0.02), and less CDI sepsis (7/45, 15.6% vs. 18/45, 40.0%; p 0.009) compared with patients receiving standard therapy. Tigecycline usage was not associated with adverse drug reactions or need for colectomy. Rates of ileus, toxic megacolon, mortality, and relapse were similar between the two groups. Favourable outcomes suggest that tigecycline might be considered as a potential candidate for therapeutic use in cases of sCDI refractory to standard treatment.

Inclusion of Vancomycin as Part of Broad-Spectrum Coverage Does Not Improve Outcomes in Patients with Intra-Abdominal Infections: A Post Hoc Analysis.

Management of complicated intra-abdominal infections (cIAIs) includes broad-spectrum antimicrobial coverage and commonly includes vancomycin for the empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA). Ideally, culture-guided de-escalation follows to promote robust antimicrobial stewardship. This study assessed the impact and necessity of vancomycin in cIAI treatment regimens. A post hoc analysis of the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial was performed. Patients receiving piperacillin-tazobactam (P/T) and/or a carbapenem were included with categorization based on use of vancomycin. Univariate and multivariable analyses evaluated effects of including vancomycin on individual and the composite of undesirable outcomes (recurrent IAI, surgical site infection [SSI], or death). The study cohort included 344 patients with 110 (32%) patients receiving vancomycin. Isolation of MRSA occurred in only eight (2.3%) patients. Vancomycin use was associated with a similar composite outcome, 29.1%, vs. no vancomycin, 22.2% (p = 0.17). Patients receiving vancomycin had (mean [standard deviation]) higher Acute Physiology and Chronic Health Evaluation II scores (13.1 [6.6] vs. 9.4 [5.7], p < 0.0001), extended length of stay (12.6 [10.2] vs. 8.6 [8.0] d, p < 0.001), and prolonged antibiotic courses (9.1 [8.0] vs. 7.1 [4.9] d, p = 0.02). After risk adjustment in a multivariate model, no significant difference existed for the measured outcomes. This post hoc analysis reveals that addition of vancomycin occurred in nearly one third of patients and more often in sicker patients. Despite this selection bias, no appreciable differences in undesired outcomes were demonstrated, suggesting limited utility for adding vancomycin to cIAI treatment regimens.

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA).

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients.The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance.The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria.An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

EPICO 3.0. Recommendations on invasive candidiasis in patients with complicated intra-abdominal infection and surgical patients with ICU extended stay

BackgroundAlthough in the last decade the management of invasive fungal infections has improved, a number of controversies persist regarding the management of complicated intra-abdominal infection and surgical extended length-of-stay (LOS) patients in intensive care unit (ICU). AimsTo identify the essential clinical knowledge and elaborate a set of recommendations, with a high level of consensus, necessary for the management of postsurgical patients with complicated intra-abdominal infection and surgical patients with ICU extended stay. MethodsA Spanish prospective questionnaire, which measures consensus through the Delphi technique, was anonymously answered and e-mailed by 30 multidisciplinary national experts, all of them specialists in fungal invasive infections from six scientific national societies; these experts were intensivists, anesthesiologists, microbiologists, pharmacologists and specialists in infectious diseases. They answered 11 questions drafted by the coordination group after conducting a thorough review of the literature published in the last few years. For a category to be selected, the level of agreement among the experts in each should be equal to or greater than 70%. In a second round, 73 specialists attended a face-to-face meeting which was held after extracting recommendations from the chosen topics and in which they validated the pre-selected recommendations and derived algorithm. ResultsAfter the second Delphi round, the following 11 recommendations with high degree of consensus were validated. For “surgical patients” seven recommendations were validated: (1) risk factors for invasive candidiasis (IC), (2) usefulness of blood culture and direct examination of abdominal fluid to start empirical treatment; (3) PCR for treatment discontinuation; (4) start antifungal treatment in patients with anastomotic leaks; (5) usefulness of Candida score (CS) but not (6) the Dupont score for initiating antifungal therapy in the event of anastomotic leakage or tertiary peritonitis, and (7) the administration of echinocandins as first line treatment in this special population. For “surgical ICU extended LOS patients” four recommendations were validated: (1) risk factors for IC, (2) presence of multi-colonization by Candida as a required variable of the CS, (3) starting antifungal treatment with CS≥4, and (4) to perform non-culture-based microbiological techniques in stable septic patients without evident focus. ConclusionsThe diagnosis and management of IC in ICU surgical patients requires the application of a broad range of knowledge and skills that we summarize in our recommendations. These recommendations, based on the DELPHI methodology, may help to identify potential patients, standardize their global management and improve their outcomes.

Moxifloxacin-loaded nanoemulsions having tocopheryl succinate as the integral component improves pharmacokinetics and enhances survival in E. coli-induced complicated intra-abdominal infection.

In the present work, a novel nanoemulsion laden with moxifloxacin has been developed for effective management of complicated intra-abdominal infections. Moxifloxacin nanoemulsion fabricated using high pressure homogenization was evaluated for various pharmaceutical parameters, pharmacokinetics (PK) and pharmacodynamics (PD) in rats with E. coli-induced peritonitis and sepsis. The developed nanoemulsion MONe6 (size 168 ± 28 nm and zeta potential (ZP) 24.78 ± 0.45 mV, respectively) was effective for intracellular delivery and sustaining the release of MOX. MONe6 demonstrated improved plasma (AUC(MONe6/MOX) = 2.38-fold) and tissue pharmacokinetics of MOX (AUC(MONe6/MOX) = 2.63 and 1.47 times in lung and liver, respectively). Calculated PK/PD index correlated well with a reduction in bacterial burden in plasma as well as tissues. Enhanced survival on treatment with MONe6 (65.44%) and as compared to the control group (8.22%) was a result of reduction in lipid peroxidation, neutrophil migration, and cytokine levels (TNF-α and IL6) as compared to untreated groups in the rat model of E. coli-induced sepsis. Parenteral nanoemulsions of MOX hold a promising advantage in the therapy of E. coli-induced complicated intra-abdominal infections and is helpful in the prevention of further complications like septic shock and death.

Antibiotic management of complicated intra-abdominal infections in adults: The Asian perspective.

Regional epidemiological data and resistance profiles are essential for selecting appropriate antibiotic therapy for intra-abdominal infections (IAIs). However, such information may not be readily available in many areas of Asia and current international guidelines on antibiotic therapy for IAIs are for Western countries, with the most recent guidance for the Asian region dating from 2007. Therefore, the Asian Consensus Taskforce on Complicated Intra-Abdominal Infections (ACT-cIAI) was convened to develop updated recommendations for antibiotic management of complicated IAIs (cIAIs) in Asia. This review article is based on a thorough literature review of Asian and international publications related to clinical management, epidemiology, microbiology, and bacterial resistance patterns in cIAIs, combined with the expert consensus of the Taskforce members. The microbiological profiles of IAIs in the Asian region are outlined and compared with Western data, and the latest available data on antimicrobial resistance in key pathogens causing IAIs in Asia is presented. From this information, antimicrobial therapies suitable for treating cIAIs in patients in Asian settings are proposed in the hope that guidance relevant to Asian practices will prove beneficial to local physicians managing IAIs.

Management of Complicated Intra-abdominal Infection

Management of Complicated Intra-abdominal Infection

Management of Complicated Intra-abdominal Infection - Two Cases

Management of Complicated Intra-abdominal Infection - Two Cases

Antimicrobial management of intra-abdominal infections: Literature's guidelines

Antimicrobial management of severe intra-abdominal infections (IAIs) involves a delicate balance of optimizing empirical therapy, which has been shown to improve clinical outcomes, while simultaneously reducing unnecessary antimicrobial use. Two sets of guidelines for the management of intra-abdominal infections were recently published. In 2010, the Surgical Infection Society and the Infectious Diseases Society of America (SIS-IDSA) created guidelines for the diagnosis and management of complicated IAIs. The new SIS-IDSA guidelines replace those previously published in 2002 and 2003. The World Society of Emergency Surgery (WSES) guidelines represent additional contributions, made by specialists worldwide, to the debate regarding proper antimicrobial drug methodology. These guidelines represent the conclusions of the consensus conference held in Bologna, Italy, in July 2010 during the first congress of the WSES.

New Guidelines for the Management of Complicated Intra-Abdominal Infections

New Guidelines for the Management of Complicated Intra-Abdominal Infections

Diagnosis and Management of Complicated Intra-Abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Hospital Management of Complicated Intra-abdominal infections: Pharmacoeconomic Evaluation

Complicated intra-abdominal infections (cIAIs) represent a heavy burden for the italian National Health System (NHS) and the italian society, with estimated annual costs of 1.5 and 3 billion euros, respectively. Both monotherapy and antibiotic combinations induce significantly different acquisition and administration costs but substantially equivalent therapeutic results, with average clinical effectiveness rates of 70-80%. this apparent equivalence presumably depends on the widespread trend to individualize the therapeutic strategy according to the clinical severity and the community or nosocomial origin of cIAIs, as well as to the degree of non-appropriateness when empirically choosing a first-line antibiotic.The average cost of nosocomial management of cIAI patients depends on several factors: posology, antibiotic drug acquisition, administration costs, duration of therapy, mix of antibiotic schedules, rates of the therapeutic failures, prolonged hospitalization. The introduction of a new antibiotic like tigecycline to the therapeutic arsenal leads to a small increase in average antibiotic acquisition and treatment costs per patient: this increase is proportional to the percentage of patients treated with the new antibiotic. According to a decisional model, implemented on international outcome data and italian costs, the mean cost for first-line antibiotic acquisition and the mean cost for first- and second-line antibiotic treatment represent respectively only 2% and 8% of the mean overall hospitalization cost. The mean hospitalization cost estimated by the model is noticeably higher than the mean value of Diagnosis Related Group (DRG) tariffs presumably reimbursed by the italian NHS to hospitals for cIAI-related hospitalizations. Greater overall efficiency levels in the nosocomial management of cIAI patients are achievable mainly through the reduction of non-appropriateness rates in first-line antibiotic choices and better treatment individualization, possible if the physician is offered the choice of as many valid therapeutic options as possible, in order to guarantee the best possibility of cure for each patient.

Empiric treatment options in the management of complicated intra-abdominal infections.

Complicated intra-abdominal infections remain a major challenge for surgeons and internists because of their association with high morbidity and mortality. For optimal outcome, these infections require a combination of appropriate and timely surgical source control and adjunctive broad-spectrum antimicrobial therapy. This review discusses criteria for choosing empiric antimicrobial therapy, outlines available treatment options, and highlights new antimicrobial therapies for these infections.