Severe Intra-abdominal Infection Research Articles

Evaluation of safety of early enteral nutrition in patients with severe intra-abdominal infection and intestinal fistulas

Objective: To evaluate the safety of early enteral nutrition (EEN) support in patients with severe intra-abdominal infection and intestinal fistulas. Methods: This was a retrospective cohort study. We collected relevant clinical data of 204 patients with severe intra-abdominal infection and intestinal fistulas who had been managed in the No. 1 Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University between 1 January 2017 and 1 January 2020. The patients were allocated to EEN or delayed enteral nutrition (DEN) groups depending on whether enteral nutrition had been instituted within 48 hours of admission to the intensive care unit. The primary outcome was 180-day mortality. Other outcomes included rates of intraperitoneal hemorrhage, septic shock, open abdominal cavity, bloodstream infection, mechanical ventilation, and continuous renal replacement therapy. Risk factors for mortality were analyzed by logistic regression. Results: There were no significant differences in hematological data or other baseline characteristics between the two groups at the time of admission to the intensive care unit (all P>0.05). However, septic shock (31.2% [15/48] vs. 15.4% [24/156], χ2=4.99, P=0.025), continuous renal replacement therapy (27.1% [13/48] versus 9.0% [14/156], χ2=8.96, P=0.003), and 180-day mortality (31.2% [15/48] vs. 7.7% [12/156], χ2=15.75, P<0.001) were significantly more frequent in the EEN than the DEN group (all P<0.05). Multivariate regression analysis showed that older age (OR=1.082, 95%CI:1.027-1.139,P=0.003), worse Acute Physiology and Chronic Health Evaluation (APACHE) II scores (OR=1.189, 95%CI: 1.037-1.363, P=0.013), higher C-reactive protein (OR=1.013, 95%CI:1.004-1.023, P=0.007) and EEN (OR=8.844, 95%CI:1.809- 43.240, P=0.007) were independent risk factors for death in patients with severe intra-abdominal infection and intestinal fistulas. Conclusion: EEN may lead to adverse events and increase mortality in patients with both enterocutaneous fistulas and severe abdominal infection. EEN should be implemented with caution in such patients.

Effects of rapid drug sensitivity testing for multidrug-resistant bacteria on the prognosis of patients with severe intra-abdominal infection

Objective: To examine the clinical value of rapid detection of drug-resistant bacteria by immunochromatography and the effects of rapid detection on the prognosis of patients with severe intra-abdominal infection complicated by carbapenem-resistant Enterobacteriaceae (CRE) bloodstream infection. Methods: This was a retrospective cohort study. We analyzed clinical data of 73 patients with severe abdominal infections with sepsis or septic shock complicated by CRE bloodstream infection admitted to the general surgery department of Jinling Hospital between February 2022 and February 2023. Patients were divided into a colloidal gold immunochromatographic assay (GICA) group (17 patients) and conventional testing group (56 patients) based on whether a GICA for CRE had been performed on the patients' first blood culture sample during the diagnosis and treatment process. There were no statistically significant differences between the GICA and conventional testing groups in age ([55.9±17.3] vs. [47.6±16.4] years), sex ([16 men vs. one woman ] vs. [41 men vs. 15 women]), median Charlson comorbidity index (3.0[2.0,4.0] vs. 3.0[2.0, 4.8]), septic shock (10 vs. 39), or acute kidney injury (8 vs. 40) (all P>0.05). Both groups routinely underwent traditional bacterial identification and drug susceptibility testing. Additionally, patients in the GICA group were tested directly for positive blood cultures using a GICA carbapenemase test kit. The main outcomes were mortality rates on Days 28 and 90 after the first identification of CRE bloodstream infection in both groups. We also compared the microbial clearance rate, duration of hospitalization and intensive care unit stay, and time from onset of CRE bloodstream infection to initiation of targeted and appropriate antibiotics between the two groups. Results: The rate of microbial clearance of bloodstream infection was significantly greater in the GICA group than in the conventional testing group (15/17 vs. 34/56 [60.7%], χ2=4.476, P=0.034), whereas the 28-day mortality tended to be lower in the GICA than conventional testing group [5/17 vs. 44.6% [25/56], χ2=1.250, P=0.264). The 90-day mortality (8/17 vs. 53.6% [30/56], χ2=0.222, P=0.638), median duration of hospitalization (37.0 [18.0, 46.5] days vs. 45.5 [32.2, 64.8] days, Z=-1.867, P=0.062), and median duration of intensive care unit stay (18.0 [6.5, 35.0] days vs. 32.0 [5.0, 51.8] days, Z=-1.251, P=0.209). The median time between the onset of bloodstream infection and administration of antibiotics was 49.0 (38.0, 69.0) hours in the GICA group, which is significantly shorter than the 163.0 (111.8, 190.0) hours in the conventional testing group (Z=-5.731, P<0.001). The median time between the onset of bloodstream infection and administration of appropriate antibiotics was 40.0 (34.0, 80.0) hours in the GICA group, which is shorter than in the conventional testing group (68.0 [38.2, 118.8]) hours; however, this difference is not statistically significant (Z=-1.686, P=0.093). Conclusions: GICA can provide information on carbapenemase- producing pathogens faster than traditional drug sensitivity testing, enabling early administration of the optimal antibiotics. The strategy of 'carbapenemase detection first' for managing bacterial infection has the potential to improve prognosis of patients and reduce mortality rate.

Surgical rescue strategies and techniques for severe intra-abdominal infection

Severe intra-abdominal infection is complicated with sepsis or septic shock and could also be named as intra-abdominal sepsis. Surgical rescue is an effective intervention for severe intra-abdominal infection, which can be caused by surgery, trauma or acute abdomen. Institutional factors associated with failure of surgical rescue include hospital volume, technology, surgeons and nurses. Patient factors contributing to failure include advanced age, diabetes mellitus and chronic organ dysfunction. The surgical rescue strategy for severe intra-abdominal infection includes damage control surgery and damage control resuscitation. Stepwise escalated procedures based on the severity of the infections should be performed as soon as possible to control the infection source, including removal of catheter in blood vessel, change of intra-abdominal drainage, trochar-assisted percutaneous abscess drainage (TA-PAD), laparotomy and open abdomen therapy. Since most of the pathogenic microorganisms of severe abdominal infections are multi-drug resistant bacteria expressing Klebsiella pneumoniae carbapenemase (KPC), the choice of empirical antibiotics can be guided by rapid identification of the KPC type before the results of antibiotic susceptibility testing are available, namely the antibiotic selection strategy of "enzyme first, then bacteria".

Treatment of open abdomen combined with entero-atmospheric fistula: A retrospective study

Objective: The purpose of this study was to analyze the course and outcome of patients with combined entero-atmospheric fistulas in open abdomen treatment. Methods: In this retrospective observational study, we collected data on 214 patients with open abdomen complicated by entero-atmospheric fistulas admitted to Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School from January 2012 to January 2021. We collected their basic characteristics, aetiology, treatment plan, and prognosis, including the durations of hospitalization and open treatment, time to resumption of enteral nutrition, duration and prognosis of definitive surgery, and overall prognosis. Results: Of the 214 patients with open abdomen complicated with entero-enteral fistulas, 23 (10.7%) died (11 of multiple organ failure caused by abdominal infection, five of abdominal cavity bleeding, four of pulmonary infection, one of airway bleeding, one of necrotizing fasciitis, and one of traumatic brain injury). The remaining 191 underwent definitive surgery at our hospital. The patients who underwent definitive surgery were predominantly male (156 patients, 81.7%); their age was (46.5±2.5) years. Trauma and gastrointestinal tumors (120 cases, 62.8%) predominated among the primary causes. The reasons for abdominal opening were, in order, severe abdominal infection (137 cases, 71.7%, damage control surgery (29 cases, 15.2%), and abdominal hypertension (25 cases, 13.1%). Temporary abdominal closure measures were used to classify the participants into a skin-only suture group (104 cases) and a skin-implant group (87 cases). Compared with the skin-implant group, in the skin-suture-only group the proportion of male patients was lower (74.7% [65/87] vs. 87.5% [91/104], χ2=5.176, P=0.023), the mean age was older ([48.3±2.0] years vs. [45.0±1.9] years, t=-11.671, P<0.001), there were fewer patients with trauma (32.2% [28 /87] vs. 58.7% [61/104), χ2=13.337, P<0.001), intensive care stays were shorter ([8.9±1.0] days vs. [12.7±1.6] days, t=19.281, P<0.001), total length of stay was shorter ([29.3±2.0] days vs. [31.9±2.0] days, t=9.021,P<0.001), there was a higher percentage of colonic fistulas (18.4% [16/87] vs. 8.7% [9/104], χ2=3.948, P=0.047), but fewer multiple fistulas (11.5% [10/87] vs. 34.6% [36/104], χ2=14.440, P<0.001). As to fistula management, a higher percentage of fistula sealing methods using 3D-printed intestinal stents were implemented in the skin-only suture group (60.9% [53/87] versus 43.3% [45/104], χ2=5.907, P=0.015). Compared with the implant group, the skin-only suture group had a shorter mean time to performing provisional closure ( [9.5±0.8] days vs. [16.0±0.6] days, t=66.023, P<0.001), shorter intervals to definitive surgery ( [165.0±10.7] days vs. [198.9±8.3] days, t=26.644, P<0.001), and less use of biopatches (56.3% [49/87) vs. 71.2% [74/104], χ2=4.545, P=0.033). Conclusions: Open abdomen complicated with entero-enteral fistulas is more common in male, and is often caused by trauma and gastrointestinal tumor. Severe intra-abdominal infection is the major cause of open abdomen, and most fistulae involves the small intestine. Collection and retraction of intestinal fluid and 3D-printed entero-enteral fistula stent sealing followed by implantation and skin-only suturing is an effective means of managing entero-enteral fistulas complicating open abdominal cavity. Earlier closure of the abdominal cavity with skin-only sutures can shorten the time to definitive surgery and reduce the rate of utilization of biopatches.

Linezolid in the treatment of severe intraabdominal infection: A STROBE-compliant retrospective study.

Safety concerns over bone marrow suppression and thrombocytopenia may inhibit the use of linezolid to treat intraabdominal infection (IAI). To evaluate the effectiveness, safety, and prognosis of linezolid in the treatment of severe IAI (SIAI). Patients were divided into a linezolid group and nonlinezolid group according to whether linezolid was prescribed. Subgroup analysis (thrombocytopenia treated with linezolid group (I), and thrombocytopenia treated with nonlinezolid group (II) also was performed. We evaluated the effectiveness of linezolid by analyzing the changes in white blood cells (WBC) and procalcitonin, evaluated safety by analyzing the changes in platelet counts, and evaluated patient outcomes by analyzing the length of hospital stay, the length of ICU stay, and the rates of clinical improvement. Sixty-six adult SIAI patients were treated with anti-gram-positive (G+) bacteria drugs for more than 7 days from January 1, 2014, to December 31, 2020. The length of hospital stay, the length of ICU stay, and the rates of clinical improvement were not significantly different between the linezolid group and nonlinezolid group. On the 15th day after anti-G + bacteria treatment, the WBC of the linezolid group was significantly lower than in the nonlinezolid group (9.00 ± 4.30 vs 13.1 ± 6.19, P < .05). The time for a statistical difference in the decrease of procalcitonin in the linezolid group was earlier than in the nonlinezolid group (day 6 vs day 7, P < .05). There was no statistically significant difference in the changes of platelet counts in the subgroup I (P > .05), but compared with the baseline data (day 0), the time for the statistical difference in the increase of platelets in thrombocytopenia treated with linezolid group was earlier (day 5 vs day 6, P < .05). There was no statistical difference in the changes of platelets in subgroup II (P > .05). In the treatment of severe intraabdominal infection in a single-center, retrospective study, linezolid was not inferior to other antibiotics in patient clinical outcomes or seral WBC and procalcitonin values. Linezolid also induced no evident bone marrow suppression or thrombocytopenia. Linezolid is a good choice for treatment of SIAI.

Open abdomen: is a dedicated emergency surgery team needed? A single center retrospective study on 141 consecutive patients.

Open Abdomen (OA) is widely used when facing a catastrophic abdomen. Still, no indication is validated by a strong and high quality of evidence. The study reports the 5year experience of a dedicated emergency general surgery (EGS) team. Retrospective observational cohort study. Patients undergoing OA management from 2/01/2015 to 19/07/2020 for trauma, non-traumatic emergencies or rescue surgery. One hundred and forty-one patients. Age 66.9 ± 15.1. Male 58.2%.9.3% OA for trauma, 64.5% for non-traumatic emergencies and 26.2% for rescue surgery. 40.4% performed by the EGS team 52.4% indication for surgery was a severe intra-abdominal infection. TAC device: commercial negative pressure wound therapy (NPWT) (83%), Sandwich VAC (12%), commercial NPWT with polypropylene mesh (5%) for pregressive fascial traction. Enteroatmospheric fistula (EAF) in 3 patients. OA duration 5.3 days (1-25). A 1.8 revision surgeries (0-12) required for definitive closure; ICU stay 9.9 days (0-78). 30-day mortality 23.5%. Overall and 1-year mortality were 47.5% and 43.3%. Overall survival 9.9months. An increased one-year mortality rate was found in the >65 group (P=0.01). We reported a wide use of OA in septic abdomen (90% of cases). We had a low rate of EAF, short ICU stay and OA duration. These results are related to the fact that patients were treated by a dedicated EGS team, suggesting that OA management should be cared for as much as possible by trained and experienced surgeons. Prospective studies with more accurate patient selection are needed to prove our conclusions.

Comparison of operative outcomes between monopolar and bipolar coagulation in hepatectomy: a propensity score-matched analysis in a single center

BackgroundVarious hemostatic devices have been utilized to reduce blood loss during hepatectomy. Nonetheless, a comparison between monopolar and bipolar coagulation, particularly their usefulness or inferiority, has been poorly documented. The aim of this study is to reveal the characteristics of these hemostatic devices.MethodsA total of 264 patients who underwent open hepatectomy at our institution from January 2009 to December 2018 were included. Monopolar and bipolar hemostatic devices were used in 160 (monopolar group) and 104 (bipolar group) cases, respectively. Operative outcomes and thermal damage to the resected specimens were compared between these groups using propensity score matching according to background factors. Multivariate logistic regression analysis was performed to identify predictive factors for postoperative complications.ResultsAfter propensity score matching, 73 patients per group were enrolled. The monopolar group had significantly lower total operative time (239 vs. 275 min; P = 0.013) and intraoperative blood loss (487 vs. 790 mL; P < 0.001). However, the incidence rates of ascites (27.4% vs. 8.2%; P = 0.002) and grade ≥ 3 intra-abdominal infection (12.3% vs. 2.7%; P = 0.028) were significantly higher in the monopolar group. Thermal damage to the resected specimens was significantly longer in the monopolar group (4.6 vs. 1.2 mm; P < 0.001). Use of monopolar hemostatic device was an independent risk factor for ascites (odds ratio, 5.626, 95% confidence interval 1.881–16.827; P = 0.002) and severe intra-abdominal infection (odds ratio, 5.905, 95% confidence interval 1.096–31.825; P = 0.039).ConclusionsAlthough monopolar devices have an excellent hemostatic ability, they might damage the remnant liver. The use of monopolar devices can be one of the factors that increase the frequency of complications.

Antimicrobial Lessons From a Large Observational Cohort on Intra-abdominal Infections in Intensive Care Units.

Severe intra-abdominal infection commonly requires intensive care. Mortality is high and is mainly determined by disease-specific characteristics, i.e. setting of infection onset, anatomical barrier disruption, and severity of disease expression. Recent observations revealed that antimicrobial resistance appears equally common in community-acquired and late-onset hospital-acquired infection. This challenges basic principles in anti-infective therapy guidelines, including the paradigm that pathogens involved in community-acquired infection are covered by standard empiric antimicrobial regimens, and second, the concept of nosocomial acquisition as the main driver for resistance involvement. In this study, we report on resistance profiles of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecalis and Enterococcus faecium in distinct European geographic regions based on an observational cohort study on intra-abdominal infections in intensive care unit (ICU) patients. Resistance against aminopenicillins, fluoroquinolones, and third-generation cephalosporins in E. coli, K. pneumoniae and P. aeruginosa is problematic, as is carbapenem-resistance in the latter pathogen. For E. coli and K. pneumoniae, resistance is mainly an issue in Central Europe, Eastern and South-East Europe, and Southern Europe, while resistance in P. aeruginosa is additionally problematic in Western Europe. Vancomycin-resistance in E. faecalis is of lesser concern but requires vigilance in E. faecium in Central and Eastern and South-East Europe. In the subcohort of patients with secondary peritonitis presenting with either sepsis or septic shock, the appropriateness of empiric antimicrobial therapy was not associated with mortality. In contrast, failure of source control was strongly associated with mortality. The relevance of these new insights for future recommendations regarding empiric antimicrobial therapy in intra-abdominal infections is discussed.

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.

An Open-Label, Multicenter, Observational Study of The Effectiveness of The Cefepime/Sulbactam Antibiotic (Maxictam&lt;sup&gt;®&lt;/sup&gt;-AF) In Patients With Intra Abdominal Infection, Nosocomial Pneumonia or Ventilator-Associated Pneumonia (Study MAXI-2019)

The aim of the study was to evaluate the effectiveness of cefepime/sulbactam in patients with intra-abdominal infection, nosocomial pneumonia (NP) or ventilator-associated pneumonia (VAP) in actual clinical practice. Material and methods. The study was conducted in 14 Russian Clinics from October 2019 to March 2020. Study design: an open-label, prospective, non-comparative, multicenter, observational study. The study included patients who met the inclusion/exclusion criteria and signed a written informed consent. The studied antibiotic: cefepime/sulbactam (Maxictam®-AF). The primary parameter for effectiveness evaluation was the clinical effect after the conclusion of cefepime/sulbactam therapy — recovery/improvement or no effect. Results. The study included 140 patients (average age — 60.8 years) who received at least one dose of cefepime/sulbactam; 37 of them had intraabdominal infection, 72 — NP, and 31 — VAP. Most of the included patients were in the ICU department (82.1%) and their condition was severe: the average APACHE II score was 15.5 points, SOFA — 5.4 points, the Mannheim peritonitis index value in patients with intra-abdominal infection was from 14 to 35 points, with an average of 24.3 points. The majority of patients treated with cefepime/sulbactam (68.6%) had one or more risk factors for multi-resistant pathogens upon hospital or ICU admission. Cefepime/sulbactam was prescribed as the 1st or 2nd line of empirical therapy at a daily dose of 4 g (in 68.3%), 6 g (2.9%) or 8 g (28.8%); most patients were prescribed cefepime/sulbactam in monotherapy (72.3%). The average duration of therapy with cefepime/sulbactam was 9.6±3.5 days. The final assessment of treatment effectiveness was carried out in 132 patients: recovery or improvement was noted in 80.6% of patients with intra-abdominal infection, the effectiveness in NP and VAP was slightly higher — 95.6 and 89.3%. The effect was absent in 5.3% of patients, relapse or superinfection was noted in 3.0 and 1.5%. The majority of patients (81.3%) treated with cefepime/sulbactam were discharged from the hospital. No serious side effects were observed. In patients with a positive effect, age and values of APACHE II were significantly lower (59.58 years and 14.79 points) compared to those with no effect (67.95 years and 18.39 points). A multivariate analysis found that the probability of recovery of patients treated with cefepime/sulbactam did not depend on the diagnosis of infection, ICU admission, the presence of sepsis or septic shock. Conclusion. The multicenter study has established a high clinical efficacy of cefepime/sulbactam in real clinical practice in the treatment of patients with severe intraabdominal infection, nosocomial pneumonia or ventilator-associated pneumonia.

Open abdomen management for severe peritonitis in elderly. Results from the prospective International Register of Open Abdomen (IROA): Cohort study.

Analyzing the data of the International Register of Open Abdomen (IROA), the feasibility of open abdomen treatment has been demonstrated at every age. This new analysis on the IROA database investigates the risk factors for mortality in elderly patients treated with open abdomen for intra-abdominal infection. Data were derived from the IROA, a prospective observational international cohort study that enrolled patients treated with open abdomen worldwide. A univariate analysis of potential risk factors was performed. Inclusion criteria were patients older than 65 years and treated with open abdomen for intra-abdominal infection. End point was overall mortality, calculated within 30 days after open abdomen management, after 1-month and 1-year follow-up. A total of 116 patients was analyzed with mean age of 76 ± 7 years. Definitive closure was achieved in 93 patients (93/116, 80.2%) for a mean open abdomen duration of 5.0 ± 5.0 days. Complicated patients were 101 (101/116, 87.1%) for a total of 201 complications. Overall, 62 out of 116 patients (53.4%) died: 23 patients (23/62, 37.1%) during open abdomen management, 29 patients (46.8%) within 30 days after abdominal closure, 9 patients (14.5%) after 1-month follow-up, and 1 patient (1.6%) after 1-year follow-up. Age did not affect mortality (75 ± 6 years in alive patients versus 77 ± 7 years in dead patients, p = 0.773). Definitive abdominal closure was the most important factor to prevent mortality. This study confirmed that age alone cannot be considered a determinant for death, even in elderly patients managed with open abdomen for severe intra-abdominal infection.

Role of Double-Lumen Irrigation-Suction Tube Drainage in Severe Intra-Abdominal Infection Induced by Endoscopic Sphincterotomy– Related Perforation

This study aimed to assess the efficacy of double-lumen irrigation-suction tube (DLIST) in treating severe intra-abdominal infection (SIAI) induced by endoscopic sphincterotomy-related perforation (EST-rP). We enrolled 34 consecutive patients who had been transferred to our hospital with SIAI induced by EST-rP from January 2000 to June 2018. Then they were assigned into two groups based on whether or not rescue surgery had been performed: failed nonoperative treatment group (n = 9) and failed rescue surgery treatment group (n = 25). All 34 patients received DLIST for positive draining by surgery in our hospital. Data collection included demographics, indication for endoscopic retrograde cholangiopancreatography, time to rescue surgery, surgical procedure, surgical success rate, complications, hospital stay, and postoperative outcome. The research enrolled 34 patients (ages 27-79 years, mean of 57.8 ± 12.1 years). There were no significant differences in age and gender between two groups (P > 0.05). After being admitted, they were diagnosed with sepsis induced by SIAI (Sequential Organ Failure Assessment score range of 2-6, mean of 3.6 ± 0.95). The time from endoscopic retrograde cholangiopancreatography to rescue surgery was 12 to 336 hours (mean of 73.7 ± 72.2 hours); overall hospital stay was 15 to 405 (mean of 127.5 ± 81.5) days. The hospital stay was significantly longer in the failed rescue surgery group than that of the failed nonoperative treatment group (P < 0.05). The overall mortality rate was 11.8 per cent (4/34). The mortality rate was 16 per cent (4/25) and 0 per cent (0/9), respectively. As a modified suction technology, DLIST placement can effectively treat SIAI induced by EST-rP and lower the mortality rate of rescue surgery treatment.

Effect of alveolar macrophages phagocytosis on prognosis in patients with acute respiratory distress syndrome caused by abdominal infection: a multicenter study

To investigate the effects of alveolar macrophage phagocytosis on prognosis in patients with acute respiratory distress syndrome (ARDS) caused by abdominal infection. ARDS patients caused by severe intra-abdominal infection admitted to intensive care unit (ICU) of Tianjin Fourth Central Hospital, Tianjin Nankai Hospital, Tianjin First Central Hospital and Tianjin Fifth Central Hospital from June 2016 to March 2018 were enrolled. The gender, age, acute physiology and chronic health evaluation II (APACHE II) within 24 hours of admission, neutral red phagocytosis and alkaline phosphatase activity of macrophages in bronchoalveolar lavage fluid, the length of ICU stay, total hospitalization time, hospitalization expenses, and prognosis were recorded. According to the prognosis, the patients were divided into death group and survival group, and the parameters were compared between the two groups. Pearson test was used to analyze the correlation between neutral red phagocytosis function of macrophages and alkaline phosphatase activity and other indicators. The prognosis was analyzed by binary Logistic regression combined with neutral red phagocytosis and alkaline phosphatase activity in patients, and the predictive value of both subjects on prognosis was analyzed by the receiver operating characteristic (ROC) curve. Twenty patients were enrolled in the study, with 8 in the death group and 12 in the survival group. Compared with the survival group, the death group was older (years old: 58.50±14.86 vs. 46.67±13.40), APACHE II score was higher (21.50±3.93 vs. 13.58±4.12), neutral red phagocytosis ability and alkaline phosphatase activity of alveolar macrophages were significantly decreased (A value: 0.265±0.050 vs. 0.338±0.016; μmol/L: 12.06±1.24 vs. 17.96±3.90), and the length of ICU stay was significantly longer (days: 22.00±14.59 vs. 11.50±3.17), hospitalization cost was significantly increased (10 thousand Yuan: 24.17±11.02 vs. 13.44±3.53), the total hospitalization time was shorter (days: 25.25±15.01 vs. 35.67±8.58), and the difference was statistically significant (all P < 0.05). There was no significant difference in gender between the survival group and the death group [male (case): 8 vs. 6, P > 0.05]. The neutral red phagocytosis ability of alveolar macrophages in ARDS patients caused by abdominal infection was negatively correlated with age, APACHE II score and the length of ICU stay (r value was -0.328, -0.572, -0.809, respectively, all P < 0.05); alkaline phosphatase activity was negatively correlated with age, APACHE II score, the length of ICU stay and hospitalization expenses (r value was -0.334, -0.583, -0.470, -0.517, respectively, all P < 0.05). Binary Logistic regression analysis showed that neutral red phagocytosis [odds ratio (OR) = 0.596, 95% confidence interval (95%CI) = 0.212-0.997] and alkaline phosphatase activity (OR = 0.573, 95%CI = 0.339-0.968) were the influencing factors of prognosis (both P < 0.05). ROC curve analysis showed that the AUC of neutral red phagocytosis ability for prognosis of ARDS patients caused by abdominal infection was 0.948, and the sensitivity and specificity were 91.7% and 87.5% when the off-cut value was 0.317. The AUC of alkaline phosphatase for the prognosis of ARDS patients caused by abdominal infection was 0.813; when the cut-off value was 19.72 μmol/L, the sensitivity was 75.0%, and the specificity was 87.5%. The alveolar macrophage phagocytosis dysfunction in ARDS patients caused by severe abdominal infection was not only related to the severity of the disease, but also increased the medical burden of patients, and significantly affected the mortality of such patients.

Efficacy of Coupled Plasma Filtration Adsorption in Treating Patients with Severe Intra-Abdominal Infection: A Retrospective Study.

Background: Coupled plasma filtration adsorption (CPFA) is an extracorporeal treatment based on plasma filtration associated with an adsorbent cartridge and hemofiltration. CPFA is able to remove inflammatory mediators and it has been used to treat severe sepsis and multiple organ dysfunction. Limited experience exists on the use of CPFA in treating intra-abdominal infection (IAI). Methods: In this study, the efficacy of CPFA in treating patients with severe IAI and liver failure was evaluated in a retrospective analysis of 76 cases. Results: The survival rate of patients treated with CPFA was 82.6%, with effective removal of endotoxin and inflammatory mediators. Conclusion: Our data suggest that CPFA can be safely and effectively used to lower morbidity and mortality rates of patients with severe IAI and liver failure.

Diagnosis and treatment of intra-abdominal infection complicated with hypothyroidism

Intra-abdominal infection complicated with hypothyroidism is very common. It mostly featured decreased T3, with or without decreased T4, and without elevated thyroid stimulating hormone(TSH). This particular type of hypothyroidism was called "low T3 syndrome" or "thyroid illness syndrome", and is called "non-thyroid illness syndrome" increasingly in recent years. Its pathogenesis has not been fully understood, and probably is associated with abnormality of hypothalamic-pituitary-thyroid axis, disorder of peripheral thyroid hormone metabolism, change in thyroid hormone binding protein, regulation of triiodothyronine receptors, effect of cytokines, and lack of trace element selenium. Intra-abdominal infection complicated with hypothyroidism should be differentiated from primary hypothyroidism, which may be one cause of mental depression, insufficient anabolism, and poor tissue healing. Therefore, the changes of T3 and T4 levels should be actively monitored in patients with severe or prolonged intra-abdominal infection. Whether treatment is needed for intra-abdominal infection complicated with hypothyroidism remains controversial. T3 replacement therapy may improve prognosis. When low T3 syndrome presents as a disease-mediated hypothyroidism, we recommend the use of levothyroxine(L-T4) or liothyronine (L-T3) treatment to improve the prognosis of critical patients. Enteral nutrition can improve hypothyroidism and has good efficacy for enterocutaneous fistula patients with intra-abdominal infection.

Immunological characteristics of peritoneal cavity and intra-abdominal infection

Despite the evolution of aggressive surgical techniques, extensive methods of supportive care and a vast array of anti-microbial options, intra-abdominal infection (IAI) is still a challenging clinical issue. Especially, when progressed IAI with septic complications because of unbalanced immune responses, the prognosis will deteriorated significantly. Recent studies indicate that besides the natural immunological cells, including macrophages and neutrophils, local immunological characteristics of peritoneal cavity should be studied with great attention. Among them, the omentum is considered to be a visceral adipose tissue with unique immune function. The milky spots(MSs) formed by the accumulation of immune cells performs immune surveillance and has a lymph node-like immune function, which is very important for the immune defense of the abdominal cavity. B1 cells and two types of intrinsic lymphocytes(ILC2) in the peritoneal cavity, although belonging to the lymphatic lineage, may play an important role in abdominal infections, especially in the early stages of the disease, due to their rapid responsiveness and acquired immune function. Therefore, paying attention to the immunological characteristics of the peritoneal cavity, and elucidating the changes, functions and regulatory mechanisms of B1 cells and ILC2 around the MSs and their components in the process of IAI, in order to explore the immunomodulation targets of blocking the infection from local to systemic dissemination, may be the key to solving the clinical problem of severe IAI and improving prognosis.

Liver Abscess and Septic Pulmonary Embolism. Description of Two Clinical Cases and Review of the Literature

Liver abscess is a common and severe intra-abdominal infection. There are geographical differences regarding its etiology. While in Asia Klebsiella (k.) pneumoniae prevailes, in US is also having a major significance. In Europe, Escherichia Coli, Staphylococcus sp. and Streptococcus sp.

Pharmacokinetic study of anidulafungin in ICU patients with intra-abdominal candidiasis.

Only limited pharmacokinetic data are available for anidulafungin in ICU patients, especially in patients treated for severe intra-abdominal infection (IAI). This was a prospective multicentre observational study in ICU patients with suspected yeast IAI. All patients received an intravenous loading dose of 200 mg of anidulafungin, followed by 100 mg/day. Thirteen blood samples were drawn between day 1 and day 5 for pharmacokinetic analysis. Samples were analysed by an HPLC-tandem MS method. Demographics and SAPS2 and SOFA scores were recorded. Fourteen patients with a median age (IQR) of 62 years (48-70) and with a mean BMI of 30.5 kg/m 2 were included from three centres; 57.1% were women. Their median (IQR) SAPS2 score was 54 (45-67) and their median (IQR) SOFA score was 8 (7-12). Six patients with community-acquired IAI and eight patients with nosocomial-acquired IAI were included. Twelve yeasts were isolated: six Candida albicans , two Candida glabrata , two Candida tropicalis , one Candida parapsilosis and one Candida krusei . Pharmacokinetic parameters were as follows [mean (% coefficient of variation)]: C max (mg/L) = 6.0 (29%); T max (h) = 1.6 (25.8%); C min (mg/L) = 3.2 (36.8%); AUC 0-24 (mg·h/L) = 88.9 (38.6%); t 1/2 (h) = 42.1 (68.2%); CL (L/h) = 1.2 (42.3%); and V (L) = 72.8 (87.8%). A two-compartment model best described the anidulafungin concentrations in the population pharmacokinetic study. The pharmacokinetic parameters of anidulafungin in critically ill ICU patients with complicated IAI are similar to those observed in the literature. However, an increased V and a longer t 1/2 were observed in this study. (EudraCT No. 2010-018695-25).

Prognostic value of presepsin for outcomes and complications in enterocutaneous fistula complicated by abdominal sepsis

BackgroundEnterocutaneous fistula (ECF) poses a supreme challenge for the surgeons associated with abdominal sepsis, fluid electrolyte imbalance and undernutrition. Individual prognostic stratification is pivotal in the clinical management. Presepsin is a novel biomarker showing diagnostic and prognostic value in sepsis. We aimed to evaluate the prognostic value of presepsin in ECF. MethodsConsecutive patients with ECF were enrolled if diagnosed as abdominal sepsis from June 2014 to June 2015. Serum concentration of presepsin at admission was measured, and medical records including demographics, medical history, treatment modalities, complications and outcomes were collected. Kaplan-Meier curves was drawn to demonstrate the cumulative incidence of source control of infection and fistula closure, and Cox regression analysis was performed to identify independent factors. Association between presepsin and other markers was evaluated by Pearson's correlation coefficient. Results71 patients were included with the median presepsin concentration of 726 pg/mL at admission. Baseline presepsin levels showed predictive potential in successful source control of intra-abdominal infection but not in fistula closure. Patients with higher presepsin had more severe intra-abdominal infection as denoted by higher levels of WBC, CRP and PCT, as well as high risks of complications and failure of fistula closure compared with those having lower presepsin (≤726 pg/mL). Presepsin concentration was positively associated with APACHE II score, CRP and PCT. ConclusionsPresepsin shows prognostic values for source control of abdominal sepsis and clinical courses of ECF. This index may help stratify patients, facilitating the monitoring and adjustment of the therapeutic regimen at an early stage.

Therapeutic Potential of Cerium Oxide Nanoparticles for the Treatment of Peritonitis Induced by Polymicrobial Insult in Sprague-Dawley Rats

Peritonitis is a life-threatening disease that is associated with high mortality. The purpose of this study was to determine if cerium oxide nanoparticles can be used to diminish intra-abdominal infection-induced mortality and systemic inflammatory response syndrome in the laboratory rat. Randomized, controlled animal study and cell culture study. University research laboratory. Male Sprague-Dawley rats aged 12 weeks, RAW 246.7 macrophage cell line. Intra-abdominal infection or peritonitis was induced by intraperitoneal injection of cecal material (600 mg/kg in 5% sterile dextrose water at a dosage of 5 mL/kg) obtained from healthy donors. Rats in control and peritonitis groups received 200 μL of sterile deionized water IV via the tail vein, whereas rats in cerium oxide-only group and peritonitis+cerium oxide group received cerium oxide nanoparticles (0.5 mg/kg) IV at the time of polymicrobial injection. Survival rate was monitored for 14 days, while in other experiments, animals were killed at 3 and 18 hours after induction of peritonitis for biochemical analysis. Administration of a single dose (0.5 mg/kg) of cerium oxide nanoparticles IV to rats in the peritonitis group significantly improved survival rates and functioned to restore core body temperature toward baseline. Treatment-induced increases in animal survivability were associated with reduced systemic and hepatic oxidative stress, diminished serum cytokines, and chemokine levels. Changes in serum inflammatory markers with treatment were accompanied by decreased monocyte and lymphocyte extravasation into the peritoneal cavity along with decreased infiltration of macrophages into liver. In the heart, treatment diminished extracellular signal-regulated kinase 1/2 mitogen-activated protein kinase-Stat-3 signaling and attenuated endothelial expression of P-selectin and vascular cell adhesion molecule-1. Cerium oxide nanoparticles attenuate the systemic inflammatory response associated with peritonitis, suggesting potential use as a novel therapeutic agent for the treatment of severe intra-abdominal infection.