Management Of Intra-abdominal Infections Research Articles

The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update.

Background: The Surgical Infection Society (SIS) published evidence-based guidelines for the management of intra-abdominal infection (IAI) in 1992, 2002, 2010, and 2017. Here, we present the most recent guideline update based on a systematic review of current literature. Methods: The writing group, including current and former members of the SIS Therapeutics and Guidelines Committee and other individuals with content or guideline expertise within the SIS, working with a professional librarian, performed a systematic review using PubMed/Medline, the Cochrane Library, Embase, and Web of Science from 2016 until February 2024. Keyword descriptors combined "surgical site infections" or "intra-abdominal infections" in adults limited to randomized controlled trials, systematic reviews, and meta-analyses. Additional relevant publications not in the initial search but identified during literature review were included. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was utilized to evaluate the evidence. The strength of each recommendation was rated strong (1) or weak (2). The quality of the evidence was rated high (A), moderate (B), or weak (C). The guideline contains new recommendations and updates to recommendations from previous IAI guideline versions. Final recommendations were developed by an iterative process. All writing group members voted to accept or reject each recommendation. Results: This updated evidence-based guideline contains recommendations from the SIS for the treatment of adult patients with IAI. Evidence-based recommendations were developed for antimicrobial agent selection, timing, route of administration, duration, and de-escalation; timing of source control; treatment of specific pathogens; treatment of specific intra-abdominal disease processes; and implementation of hospital-based antimicrobial agent stewardship programs. Summary: This document contains the most up-to-date recommendations from the SIS on the prevention and management of IAI in adult patients.

Management of Intra-Abdominal Infections: The Role of Procalcitonin.

Patients with intra-abdominal sepsis suffer from significant mortality and morbidity. The main pillars of treatment for intra-abdominal infections are (1) source control and (2) early delivery of antibiotics. Antibiotic therapy should be started as soon as possible. However, the duration of antibiotics remains a matter of debate. Prolonged antibiotic delivery can lead to increased microbial resistance and the development of nosocomial infections. There has been much research on biomarkers and their ability to aid the decision on when to stop antibiotics. Some of these biomarkers include interleukins, C-reactive protein (CRP) and procalcitonin (PCT). PCT's value as a biomarker has been a focus area of research in recent years. Most studies use either a cut-off value of 0.50 ng/mL or an >80% reduction in PCT levels to determine when to stop antibiotics. This paper performs a literature review and provides a synthesized up-to-date global overview on the value of PCT in managing intra-abdominal infections.

Clarithromycin-Loaded Submicron-Sized Carriers: Pharmacokinetics and Pharmacodynamic Evaluation.

The current study aims to improve clarithromycin bioavailability and effectiveness in complicated intra-abdominal infection management. Therefore, clarithromycin-loaded submicron dual lipid carriers (CLA-DLCs) were developed via hot high shear homogenization technique and evaluated for colloidal parameters, release behavior, stability study, and in-vitro antibiofilm activity. Bioavailability and therapeutic efficacy of optimized formulation on hampering cytokines storm induction was determined in E. coli-induced peritonitis. The developed CLA-DLCs (particle size 326.19 ± 24.14 nm, zeta potential -31.34 ± 2.81 mV, and entrapment efficiency 85.78 ± 4.01%) exhibited smooth spherical shapes and sustained in vitro release profiles. Long-term stability study of optimized CLA-DLCs ensured maintenance of colloidal parameters for 1 year at room temperature. In vitro antimicrobial studies revealed 3.43-fold higher anti-biofilm activity of CLA-DLCs compared with clarithromycin. In addition, the relative bioavailability of CLA-DLCs was enhanced 5.89-fold compared to pure drug in rats. The remarkable decrease in microbial burden in blood as well as tissues, along with oxidative stress markers (lipid peroxidation, myeloperoxidase activity, and carbonylated protein level) and immunological markers (total leukocyte count, neutrophil migration, NO, TNF-, and IL-6) on treatment with CLA-DLCs enhanced the survival in a rat model of peritonitis compared with the pure drug and untreated groups. In conclusion, CLA-DLCs hold promising potential in management of intra-abdominal infections and prevention of associated complications.

Sepsis Team Organizational Model to Decrease Mortality for Intra-Abdominal Infections: Is Antibiotic Stewardship Enough?

Introduction. Sepsis is an overwhelming reaction to infection with significant morbidity, requiring urgent interventions in order to improve outcomes. The 2016 Sepsis-3 guidelines modified the previous definitions of sepsis and septic shock, and proposed some specific diagnostic and therapeutic measures to define the use of fluid resuscitation and antibiotics. However, some open issues still exist. Methods. A literature research was performed on PubMed and Cochrane using the terms "sepsis" AND "intra-abdominal infections" AND ("antibiotic therapy" OR "antibiotic treatment"). The inclusion criteria were management of intra-abdominal infection (IAI) and effects of antibiotic stewardships programs (ASP) on the outcome of the patients. Discussion. Sepsis-3 definitions represent an added value in the understanding of sepsis mechanisms and in the management of the disease. However, some questions are still open, such as the need for an early identification of sepsis. Sepsis management in the context of IAI is particularly challenging and a prompt diagnosis is essential in order to perform a quick treatment (source control and antibiotic treatment). Antibiotic empirical therapy should be based on the kind of infection (community or hospital acquired), local resistances, and patient's characteristic and comorbidities, and should be adjusted or de-escalated as soon as microbiological information is available. Antibiotic Stewardship Programs (ASP) have demonstrated to improve antimicrobial utilization with reduction of infections, emergence of multi-drug resistant bacteria, and costs. Surgeons should not be alone in the management of IAI but ideally inserted in a sepsis team together with anaesthesiologists, medical physicians, pharmacists, and infectious diseases specialists, meeting periodically to reassess the response to the treatment. Conclusion. The cornerstones of sepsis management are accurate diagnosis, early resuscitation, effective source control, and timely initiation of appropriate antimicrobial therapy. Current evidence shows that optimizing antibiotic use across surgical specialities is imperative to improve outcomes. Ideally every hospital and every emergency surgery department should aim to provide a sepsis team in order to manage IAI.

Інтраабдомінальна інфекція у світлі останніх міжнародних рекомендацій та її роль у розвитку септичної енцефалопатії

Мета цих рекомендацій: представити міжнародну позицію, засновану на доказах, із питань застосування методів ведення внутрішньоабдомінальних інфекцій та вплив внутрішньоабдомінальних інфекцій на розвиток септичної енцефалопатії. Ускладнена інтраабдомінальна інфекція є важливою причиною захворюваності та смертності. В уявленні Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) сепсис визначається як загрозлива для життя дисфункція органа, що викликана дисрегуляторною відповіддю хазяїна на інфекцію. Дисфункція органа може бути подана як збільшення показника на більше ніж 2 бала за шкалою Sequential Organ Failure Assessment (SOFA). Раннє виявлення пацієнтів з абдомінальним сепсисом є важливим кроком для ефективного лікування з метою покращання результатів. Мікросудинна дисфункція, глобальне пошкодження тканин можуть призвести до розвитку септичної енцефалопатії, що асоціюється з поганим прогнозом. Ключовими факторами ефективної терапії внутрішньоабдомінальних інфекцій є оперативний діагноз, адекватна реанімація, ранній початок відповідної антибактеріальної терапії, ранній конт­роль джерела інфекції та постійна переоцінка клінічної відповіді на тактику ведення. Оцінка ефективності рекомендацій та якості доказів подані відповідно до Grading of Recommendations Assessment, Development and Evaluation (GRADE).

The Need of Enterococcal Coverage in Severe Intra-Abdominal Infection: Evidence from Animal Study.

Intra-abdominal infection (IAI) is a common and important cause of infectious mortality in intensive care units. Adequate source control and appropriate antimicrobial regimens are key in the management of IAI. In community-acquired IAI, guidelines recommend the use of different antimicrobial regimens according to severity. However, the evidence for this is weak. We investigated the effect of enterococcal coverage in antimicrobial regimens in a severe polymicrobial IAI model. We investigated the effects of imipenem/cilastatin (IMP) and ceftriaxone with metronidazole (CTX + M) in a rat model of severe IAI. We observed the survival rate and bacterial clearance rate. We identified the bacteria in blood culture. We measured lactate, alanine aminotransferase (ALT), creatinine, interleukin (IL)-6, IL-10, and reactive oxygen species (ROS) in the blood. Endotoxin tolerance of peripheral blood mononuclear cells (PBMCs) was also estimated to determine the level of immune suppression. In the severe IAI model, IMP improved survival and bacterial clearance compared to CTX + M. Enterococcus spp. were more frequently isolated in the CTX + M group. IMP also decreased plasma lactate, cytokine, and ROS levels. ALT and creatinine levels were lower in IMP group. In the mild-to-moderate IAI model, however, there was no survival difference between the groups. Immune suppression of PBMCs was observed in IAI model, and it was more prominent in the severe IAI model. Compared to CTX + M, IMP improved the outcome of rats in severe IAI model.

Expert consensus on multidisciplinary management of intra-abdominal infections

Intra-abdominal infections(IAIs) are common surgical emergencies and complications, which usually need multidisciplinary management including surgeons, intensivists, infectious disease experts, microbiologists, and clinical pharmacists. Based on international and domestic guidelines and recent advances, a number of experts' statements of consensus, with a problem-oriented approach, were made on the cornerstones of effective treatment of IAIs such as early recognition, etiology identification, adequate source control, and appropriate antimicrobial therapy. Main recommendations include concepts of intra-abdominal infection, pathoqen diagnosis precautions; surgical intervention principles and strategies of specific causes including acute appendicitis, upper gastrointestinal perforation, lower gastrointestinal perforation, acute biliary infection, liver abscess, severe acute pancreatitis, pancreatic fistula, biliary fistula, anastomotic leakage, gastrointestinal perforation, as well as perforation due to endoscopic procedure etc.; principles of antimicrobial therapy, dosage of antibiotics in specific population and pathophysiological state; and systematic support of severe infection such as early resuscitation and nutrition support.

Diagnosis and Management of Intraabdominal Infection: Guidelines by the Chinese Society of Surgical Infection and Intensive Care and the Chinese College of Gastrointestinal Fistula Surgeons

The Chinese guidelines for IAI presented here were developed by a panel that included experts from the fields of surgery, critical care, microbiology, infection control, pharmacology, and evidence-based medicine. All questions were structured in population, intervention, comparison, and outcomes format, and evidence profiles were generated. Recommendations were generated following the principles of the Grading of Recommendations Assessment, Development, and Evaluation system or Best Practice Statement (BPS), when applicable. The final guidelines include 45 graded recommendations and 17 BPSs, including the classification of disease severity, diagnosis, source control, antimicrobial therapy, microbiologic evaluation, nutritional therapy, other supportive therapies, diagnosis and management of specific IAIs, and recognition and management of source control failure. Recommendations on fluid resuscitation and organ support therapy could not be formulated and thus were not included. Accordingly, additional high-quality clinical studies should be performed in the future to address the clinicians' concerns.

Abdominal sepsis

Background. Sepsis is a life-threatening acute organ dysfunction that occurs as a result of dysregulation of the macroorganism’s response to infection. Septic shock is a variant of sepsis characterized by the circulatory failure, manifested by hypotension and increased lactate levels >2 mmol/L despite adequate infusion, which requires the administration of vasopressors to maintain average blood pressure >65 mm Hg.
 Objective. To describe the management of patients with abdominal sepsis.
 Materials and methods. Analysis of literature data on this topic.
 Results and discussion. Complicated intra-abdominal infection (IAI) is the growth of pathogenic microorganisms in a usually sterile abdominal cavity, usually due to the perforation of the hollow organs. Uncomplicated IAI involves transmural inflammation of the digestive tract, which does not spread beyond the hollow organ. If uncomplicated IAI are not treated, there is a possibility that they will progress to complicated ones. Measures to control the source of infection include the drainage of abscesses or places of accumulation of infected fluid, removal of necrotic infected tissues and restoration of the anatomy and functions of the affected area. Several multivariate studies have found that failure to adequately control the source of infection is a risk factor for adverse outcomes and death in patients with IAI. Surviving sepsis and other recommendations also support the need for early control of the source of infection. In a study by B. Tellor et al. (2012) mortality was 9.5 % among individuals with adequate control of the infection source and 33.3 % among patients who failed to achieve such control. In some situations, it is advisable to manage patients conservatively. Thus, in appendicular infiltration, most studies have demonstrated the benefits of conservative management (Andersson R.E., Petzold M.G., 2007). Management of IAI without final control of the primary source is possible in cases where the organism has already overcome the infection, and surgery can only increase the number of complications. In general, patients with localized infections may need less invasive management. Thus, percutaneous drainage can be used for localized accumulations of fluid in the abdominal cavity. 80-92 % of drainage procedures are successful on the first attempt. <5 % of patients require surgical treatment. Such drainage procedures are used in infected pancreatic necrosis, and the final debridement of the infection source may be delayed. In critically ill patients, damage control laparotomy and limited intervention (resection without reanastomosis or stoma formation, temporary drainage and tamponade of the abdominal cavity if necessary, temporary closure of the abdominal cavity) are performed to control the infection. Indications for damage control laparotomy include inability to achieve adequate control of the source of IAI during primary laparotomy, hemodynamic instability, the need to re-evaluate the condition of the problematic anastomosis, and diffuse peritonitis. A prospective study of staged laparotomies revealed a shorter length of stay in the intensive care unit, a lower incidence of complications and lower treatment costs using this method compared to the standard one. Antibacterial support of surgical interventions is an important aspect of treatment. In conditions of increasing antibiotic resistance, antibiotics should be prescribed strictly in accordance with the recommendations and for as short effective period as possible.
 Conclusions. 1. Despite the fact that approaches are changing, control of the IAI source remains the main method of treatment of most patients with IAI. 2. The choice of empirical antibacterial therapy should be based on the risk assessment and potential of resistant bacteria. 3. The duration of antimicrobial therapy can be significantly reduced (4 days).

An Evaluation of Guideline Concordance in the Management of Intra-Abdominal Infections

Background: Optimal treatment of intra-abdominal infections (IAIs) is multifaceted, typically requiring surgical intervention and antimicrobial therapy. Treatment of IAIs aligned with the 2017 revised Surgical Infection Society (SIS) guidelines may improve patient outcomes. Here we compare clinical outcomes of patients who received guideline concordant and discordant therapy for treatment of IAIs. Patients and Methods: This was a retrospective observational study of patients admitted from January 2013 to June 2016 with IAIs. Guideline concordant treatment was based on three criteria: source control, antibiotic choice, and antibiotic duration. The primary outcome was a composite of in-hospital mortality and 30-day re-admission. Multivariable logistic regression was used to determine independent factors associated with the composite end point. Results: A total of 221 patients were included, with guideline concordant treatment occurring in 117 (53%) patients. In-hospital mortality or 30-day re-admission occurred in 15 (12.8%) patients in the guideline concordant group compared with 24 (23.1%) in the guideline discordant group (p = 0.046). Empiric antibiotic choice was the most common component of discordance to guidelines (61% of patients). In multivariable analysis, guideline concordant treatment was associated with a decrease in the composite outcome (adjusted odds ratio [aOR] = 0.461, p = 0.045). In contrast, the presence of empiric methicillin-resistant Staphylococcus aureus (MRSA)/vancomycin-resistant Enterococcus (VRE) coverage (aOR: 2.645, p = 0.030), and moderate-to-severe liver disease (aOR: 8.081, p = 0.027) were associated with an increased risk for the composite outcome. Conclusions: Concordance to recommendations from the 2017 revised SIS guidelines is of critical importance in the optimal management of IAIs and further investigation of interventions to improve concordance are warranted.

Vancomycin in the treatment of adult intra-abdominal infections: do we have strong evidences?

The management of intra-abdominal infections (IAIs) primarily includes adequate antimicrobial therapy and appropriate source control. Vancomycin is a fundamental and most effective antimicrobial agent. The aim of this study is to search and evaluate the quality of clinical evidences regarding the exclusive use of vancomycin for the management of adult IAIs. For this purpose, we first summarized the recommendations on exclusive use of vancomycin in adult IAIs from six leading guidelines and excavated the relevant supporting references. We subsequently conducted a literature search to screen eligible clinical studies in this field for possible systematic review. Our investigation demonstrates that the exclusive use of vancomycin is recommended in restricted indications, that is, IAIs caused by Enterococcus spp. or methicillin-resistant Staphylococcus aureus. However, the supporting references in the guidelines are more subjective instead of objective, which mainly originate from experts’ personal experiences or from the therapeutic efficacy of vancomycin in other types of infections rather than in IAIs. Furthermore, our literature search fails to find high-level evidence. In conclusion, current low-level evidences are inadequate to elicit strong recommendations on the exclusive use of vancomycin in the treatment of adult IAIs. Our study would be helpful for the rational use of vancomycin and deceleration of the emerging vancomycin resistance rates.

1116. Comparison of Short-Course vs. Prolonged-Course Antimicrobial Therapy in the Management of Intra-Abdominal Infections

BackgroundWhen managing complicated intra-abdominal infections (IAIs), the current Infectious Diseases Society of America (IDSA) guidelines recommend an antimicrobial treatment duration of 4–7 days. Although recent evidence supports this shorter course of therapy, antimicrobials are still often administered for 10–14 days due to concern for subsequent complications. The purpose of this study was to compare clinical outcomes of short-course (SC) vs. prolonged-course (PC) antimicrobial therapy in the management of IAI at our institution.MethodsIRB-approved, single-center, retrospective cohort including all patients at the University of Toledo Medical Center who were admitted between January 1, 2012–June 30, 2017 with an IAI, received antimicrobials for ≥48 hours, and had at least one sign of IAI. Patients with concomitant infections at sites other than the abdomen, primary peritonitis or pancreatitis, immunocompromising conditions, or bacteremia were excluded. Primary outcome of clinical cure was compared between SC (≤7 days of antimicrobial treatment) and PC (>7 days) groups. Secondary outcomes included hospital length of stay (LOS), ICU LOS, 28-day all-cause mortality, and 30-day readmission. Multivariable logistic regression was performed to assess for factors associated with clinical cure.ResultsOne hundred seventy-five patients were included, 73 SC and 102 PC. Baseline characteristics were similar between groups. Rate of clinical cure for SC vs. PC was 74.0% vs. 67.6% (P = 0.367). Secondary outcomes including hospital LOS (5.5 days vs. 5.8 days, P = 0.372), ICU LOS (3.0 days vs. 5.0 days, P = 0.117), 28-day all-cause mortality (4.1% vs. 2.0%, P = 0.651), and 30-day readmission (19.2% vs. 20.6%, P = 0.818) were also not significantly different. After multivariable logistic regression, the only variable independently associated with clinical cure was diverticulitis (adjusted odds ratio 0.337, 95% CI 0.133 – 0.853).ConclusionIn patients with IAI, there was no significant difference observed in rates of clinical cure between SC and PC antimicrobial therapy. These results further support the IDSA recommendations for a shorter duration of therapy for patients with IAI.Disclosures All authors: No reported disclosures.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection.

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. 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. 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. The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

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.

Treatment Modalities and Antimicrobial Stewardship Initiatives in the Management of Intra-Abdominal Infections.

Antimicrobial stewardship programs (ASPs) focus on improving the utilization of broad spectrum antibiotics to decrease the incidence of multidrug-resistant Gram positive and Gram negative pathogens. Hospital admission for both medical and surgical intra-abdominal infections (IAIs) commonly results in the empiric use of broad spectrum antibiotics such as fluoroquinolones, beta-lactam beta-lactamase inhibitors, and carbapenems that can select for resistant organisms. This review will discuss the management of uncomplicated and complicated IAIs as well as highlight stewardship initiatives focusing on the proper use of broad spectrum antibiotics.

Comparative pharmacoeconomics and efficacy analysis of a new antibiotic adjuvant entity and piperacillin-tazobactam for the management of intra-abdominal infections: A retrospective study

ObjectiveTo analyze the comparative efficacy of piperacillin-tazobactam (PIP-TAZ) and ceftriaxone-sulbactam with adjuvant (CSA) in the treatment of intra-abdominal infections (IAIs) and to assess the costs associated with respective therapies. MethodsThe present study analyzed the data collected from 94 IAI patients treated at a tertiary-care hospital. Patient characteristics, infection types, surgical procedures, antibiotic therapies, treatment durations were recorded and overall cost involved in the infections management was estimated in Indian rupee. ResultsIn total, 46 patients received PIP-TAZ and 48 patients received CSA. The clinical cure was seen in 39.13% patients of PIP-TAZ group and 62.50% patients of CSA group. The patients diagnosed with mixed culture (Gram-positive and negative) infections, needed additional cover of clindamycin to achieve clinical success. The failure patients from PIP-TAZ group were shifted to meropenem therapy. For the patients where meropenem and CSA therapy failed, colistin was given as an additional cover. Comparative cost expenditure analysis of the two drug treatment groups revealed that, the overall treatment cost for patients cured with empirical PIP-TAZ group was 51.79% more than that of CSA therapy. The strongest predictor of the increase in treatment costs was clinical failure. Similar trends were maintained for the patients cured with clindamycin additional therapy and change of therapy, with PIP-TAZ group accounting 36.11% and 39.99% more expenditure than CSA group. ConclusionsThis study demonstrates that CSA has comparatively higher efficacy as compared to PIP-TAZ when used along with metronidazole in patients with different types of IAIs. Pharmacoeconomic analysis clearly shows that starting appropriate empirical antibiotic therapy has a large impact on the cost of treatment in management of IAIs and selection of CSA, can significantly reduce the cost involved in the treatment.

Antimicrobial and surgical management of intra-abdominal infections in children

Complicated intra-abdominal infections are a common problem in children. The etiology of these infections varies by age, with necrotizing enterocolitis being the most common cause in neonates, and appendicitis the most common cause in children. Diagnosis is based on clinical and laboratory findings as well as appropriate imaging studies. These infections are generally the result of mixed gastrointestinal flora, most commonly Escherichia coli and Bacteroides spp. The basic treatment principles for complicated intra-abdominal infections include adequate hemodynamic resuscitation, appropriate antimicrobial therapy, and source control. Antibiotic regimens should include agents effective against common Gram-negative facultative/aerobic bacilli as well as anaerobes. Increased antibiotic resistance has developed among several of the pathogens involved in these infections, which may need to be taken into consideration when selecting empiric therapy. In addition to appropriate antimicrobial therapy, adequate source control has been considered essential in the management of these infections. However, the need for definitive source control procedures in all patients has been challenged, and it has been demonstrated that deferral of these procedures or use of drainage instead of definitive procedures may suffice in selected children and neonates. The advent of laparoscopic procedures has also allowed less invasive approaches to be used in managing the nidus of infection. In this review, some aspects of the etiology, diagnosis and treatment of pediatric intra-abdominal infections will be addressed, particularly with regard to controversies in the use of antimicrobial therapy and source control procedures for these infections.

Characterization of extended-spectrum beta-lactamases and antimicrobial resistance of Klebsiella pneumoniae in intra-abdominal infection isolates in Latin America, 2008–2012. Results of the Study for Monitoring Antimicrobial Resistance Trends

The Study for Monitoring Antimicrobial Resistance Trends has monitored the in vitro activity of several recommended antimicrobials used in the management of intra-abdominal infections (IAIs) globally since 2002. In this report, we document the changing susceptibility patterns to recommended antimicrobials in Klebsiella pneumoniae isolates from patients with IAIs in 11 Latin American countries between 2008 and 2012 and describe the beta-lactamases encoded by phenotypically extended-spectrum beta-lactamase (ESBL)–positive and ertapenem-nonsusceptible isolates. Overall, the incidence of phenotypically ESBL-positive K. pneumoniae did not change significantly from 2008 (40.4%) to 2012 (41.2%) (P>0.05). However, trend analysis documented an increase in isolates encoding K. pneumoniae carbapenemase (KPC) or both KPC and an ESBL. Decreasing susceptibility (P<0.05) was noted for cefepime, ceftazidime, ceftriaxone, ertapenem, and imipenem among all K. pneumoniae, as well as for cefepime, cefotaxime, cefoxitin, ceftriaxone, ertapenem, and imipenem among ESBL-positive isolates, while susceptibility of ESBL-negative isolates to ampicillin-sulbactam actually increased (P<0.05).

Second WSES convention, WJES impact factor, and emergency surgery worldwide

BackgroundIn 2007, before founding the World Society of Emer-gency Surgery (WSES), we developed a questionnaire toinvestigate how emergency surgery was organized andimplemented as a practice throughout the world. Wediscovered two fundamental models, which were some-times present simultaneously in the same country [1].One model was characterized by hospitals with desig-nated emergency surgery departments and the other fea-tured hospitals without an emergency surgery departmentin which surgical emergencies were subdivided amongvarious general and specialized surgeons. Similarly, somehospitals had designated trauma teams while others hadno such designated units.However, despite the heterogeneous complexity of emer-gency surgery in a worldwide context, the work of sur-geons around the globe appears remarkably similarregardless of the name attributed to the facility in whichthey practice, be it emergency surgery, acute care surgery,or another generic title.Although it is difficult to succinctly define emergencysurgery, which includes a broad spectrum of procedures,a universal definition could be poly-specialized surgeryperformed for traumatic and non-traumatic acute dis-eases. We have considered non traumatic emergencysurgery as non CNS life-threatening diseases requiringurgent operative intervention (within 24 hr) with the ex-ception of those requiring total cardiac bypass.There is a significant difference between traumatic andnon-traumatic acute diseases. The dispersion of traumaprograms sponsored by the American College of Sur-geons has resulted in the near-uniform management oftrauma patients around the world. By contrast, the man-agement of patients with non-traumatic acute diseases(intra-abdominal infections, bowel occlusion, etc.) re-mains poorly standardized and varies dramatically be-tween treatment centers. Standards for the managementof non-traumatic acute diseases are just as important asthose of ATLS.Practitioners of emergency surgery worldwide must de-velop standardized guidelines to streamline protocol anddesignate organizational models used to address acute dis-eases requiring urgent surgical intervention; this ambi-tious effort is the primary objective of the World Societyof Emergency Surgery (WSES) and its publication affiliatethe World Journal of Emergency Surgery (WJES).In recent years, the WSES has focused on non-traumaticacute diseases, proposing standardized protocol guidelinesand prospective studies shared worldwide.In 2011, WSES published the first set of universalguidelines for the management of intra-abdominal infec-tions in the WJES [2]. This article was an executive sum-mary of the final recommendations approved by theconsensus conference held in Bologna, Italy, in July of2010 during the first WSES convention. These guide-lines were recently updated following a multidisciplinarycollaboration of international contributors [3].In 2011, the WSES also presented guidelines for themanagement of obstructive cancer of the left colon [4]as well as guidelines for the diagnosis and managementof adhesive small bowel obstruction [5], both publishedin the WJES. These guidelines represent a summary ofthe final recommendations approved by the consensusconference of the first WSES convention held in Bolognain 2010.In an effort to promote global sharing on the topic ofmanagement of intra-abdominal infections and to garnerinternational support and input, the WSES also conductedtwo prospective observational studies.The CIAO Study (“Complicated Intra-Abdominal in-fection Observational” Study) was a multicenter investi-gation performed in 68 medical institutions throughoutEurope over the course of a 6-month observationalperiod (January-June 2012) [6].Given the success of the CIAO Study, WSES designed

Serum procalcitonin in the diagnosis and management of intra-abdominal infections

The biomarker procalcitonin (PCT) has been used to diagnose and monitor a number of clinically significant infections. Serum levels of PCT are often increased in the presence of bacterial and fungal infections but not viral infections or noninfectious inflammation. Intra-abdominal infections (IAIs) are serious conditions that pose difficult challenges to physicians and the healthcare system. Researchers have evaluated PCT in the management of IAIs, both for diagnosis and for guiding antibiotic therapy. The studies have produced mixed results, leading to controversy on the utility of PCT in IAIs. PCT appears to be most useful in diagnosing postoperative infections and necrotizing pancreatitis. This review aims to summarize these data, explore the pathophysiology of PCT in sepsis from IAIs, discuss the strengths and weaknesses of PCT monitoring in IAIs, and provide guidance for the interpretation of PCT levels.