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Introduction: Streptococcus pneumoniae (Spn) is occasionally implicated as a cause of intra-abdominal infection (IIASpn) that can be 1) spontaneous bacterial peritonitis (SBP) in elderly patients with previous peritoneal disease, associated with cirrhosis, in most of the cases 2) associated or adjacent to an intra-abdominal organ or postsurgical. (IIAbq) 3) peritonitis in previously healthy young women (PHYW). Our objective is report 18 cases of IIASpn describing: clinical presentation, comorbidities, need for surgery, microbiological findings, sensitivity of Spn to antimicrobials, therapeutic behavior, and evolution., Methods: study of 18 adult patients with IIASpn. Clinical and microbiological characteristics and evolution of infections were analyzed., Results: IIASpn occurred in 9 PHYW, 6 men and 1 woman with SBP, and 2 men with appendicitis. The PHYW were operated on (4 pelviperitonitis, 3 salpingitis, 2 and tubo ovarian abscess) and had a favorable evolution. In the intraoperative samples, pure culture of Spn sensitive to penicillin was isolated. Three of four patients had positive blood culture. Five of seven patients with SBP died and in the peritoneal fluid developed Spn in pure culture. A large percentage of strains presented decreased sensitivity to penicillin. Four of five had a positive blood culture. Patients with appendicitis had favorable evolution., Conclusions: IIASpn in PHYW was the most frequent presentation, surgery played a significant role in treatment and the clinical response was excellent. The second presentation occurred in elderly patients with cirrhosis, most of whom died. Appendicitis was the third presentation in patients who evolved favorably., (Universidad Nacional de Córdoba)

Postoperative peritonitis (PoP), despite their relatively low incidence, are associated with high mortality. Such poor outcomes are also related to the high proportion of aged patients, whose intra-abdominal infections are difficult to manage. The study included 84 consecutive patients with PoP. The aim was the validation of the Mannheim Prognostic Index (MPI) in the context of PoP and the assessment of the prognostic impact of age and other clinical factors in a large series from a tertiary center. PoP had an incidence of 3.9% in all the abdominal surgeries in the study period. Surgical control of POP focus was achieved in 90.5% of cases and a complete abdominal clearance in 58.3%. Complication rate was 75% with a mortality of 26.2%. For MPI score, the ROC curve indicated a cut-off value of 29 with a sensitivity of 72.7% and specificity of 67.7% in predicting death. At univariate analysis, factors significantly related to poorer prognosis included advanced age (p 0.001), site of primary surgery (p 0.05), lack of abdominal clearance (p 0.003), generalized peritonitis (p 0.04) and high MPI score (p < 0.001). Age, MPI score and absence of abdominal clearance resulted in independent prognostic factors at multivariate analysis. MPI showed good efficacy in identifying POP patients at high risk of death. The increased risk of mortality related to advanced age should be considered with MPI score in planning the treatment. An aggressive and early diagnostic-therapeutic approach is required to reduce the MPI score and improve the prognosis.

This systematic review and meta-analysis investigates current evidence on the therapeutic role of laparoscopic lavage in the management of diverticular peritonitis. A systematic review of the literature was performed on PubMed until June 2016, according to preferred reporting items for systematic reviews and meta-analyses guidelines. All randomised controlled trials comparing laparoscopic lavage with surgical resection, irrespective of anastomosis or stoma formation, were analysed. After assessment of titles and full text, 3 randomised trials fulfilled the inclusion criteria. Overall the quality of evidence was low because of serious concerns regarding the risk of bias and imprecision. In the laparoscopic lavage group, there was a statistically significant higher rate of postoperative intra-abdominal abscess (RR 2.54, 95% CI 1.34-4.83), a lower rate of postoperative wound infection (RR 0.10, 95% CI 0.02-0.51), and a shorter length of postoperative hospital stay during index admission (WMD = -2.03, 95% CI -2.59 to -1.47). There were no statistically significant differences in terms of postoperative mortality at index admission or within 30 days from intervention in all Hinchey stages and in Hinchey stage III, postoperative mortality at 12 months, surgical reintervention at index admission or within 30-90 days from index intervention, stoma rate at 12 months, or adverse events within 90 days of any Clavien-Dindo grade. The surgical reintervention rate at 12 months from index intervention was significantly lower in the laparoscopic lavage group (RR 0.57, 95% CI 0.38-0.86), but these data included emergency reintervention and planned intervention (stoma reversal). This systematic review and meta-analysis did not demonstrate any significant difference between laparoscopic peritoneal lavage and traditional surgical resection in patients with peritonitis from perforated diverticular disease, in terms of postoperative mortality and early reoperation rate. Laparoscopic lavage was associated with a lower rate of stoma formation. However, the finding of a significantly higher rate of postoperative intra-abdominal abscess in patients who underwent laparoscopic lavage compared to those who underwent surgical resection is of concern. Since the aim of surgery in patients with peritonitis is to treat the sepsis, if one technique is associated with more postoperative abscesses, then the technique is ineffective. Even so, laparoscopic lavage does not appear fundamentally inferior to traditional surgical resection and this technique may achieve reasonable outcomes with minimal invasiveness.

Recommendations for the treatment of intra-abdominal infections (IAI) caused by drug-resistant bacteria often fail to mention the bacteria of concern (e.g. vancomycin-resistant enterococci, extended spectrum beta-lactamase-producing (ESBL) Enterobacteriaceae, multi-drug resistant Pseudomonas spp., carbapenem-resistant organisms and Acinetobacter spp.) and all available drugs. The group of patients suffering from IAI due to resistant bacteria includes the entire group of postoperative and tertiary peritonitis and necrotizing pancreatitis. This article provides information for the management of a very important group of diseases with a substantial morbidity and mortality. An individual patient-centered approach is mandatory to evaluate the optimal antimicrobial treatment regimen. Especially in gram-negative bacteria, which are the predominant cause only a few options remain for treatment. Clinical data with a high level of evidence are very limited. Future studies should focus on pharmacokinetic and pharmakodynamic aspects in critically ill patients, in the sense of antibiotic stewardship in order to elucidate the real life efficacy and safety of antibiotics for the treatment of life-threatening IAI.

• We report data on immunocompromised ICU patients with intra-abdominal infections. • Compared to an immunocompetent cohort in a large multinational cohort study. • Community-acquired infections were less frequent and septic shock more frequent. • Mortality was not higher. • Risk factors for death are septic shock and source control failure. We compared epidemiology of intra-abdominal infection (IAI) between immunocompromised and non-immunocompromised ICU patients and identified risk factors for mortality. We performed a secondary analysis on the " AbSeS " database, a prospective, observational study with IAI patients from 309 ICUs in 42 countries. Immunocompromised status was defined as either neutropenia or prolonged corticosteroids use, chemotherapy or radiotherapy in the past year, bone marrow or solid organ transplantation, congenital immunodeficiency, or immunosuppressive drugs use. Mortality was defined as ICU mortality at any time or 28-day mortality for those discharged earlier. Associations with mortality were assessed by logistic regression. The cohort included 2589 patients of which 239 immunocompromised (9.2 %), most with secondary peritonitis. Among immunocompromised patients, biliary tract infections were less frequent, typhlitis more frequent, and IAIs were more frequently healthcare-associated or early-onset hospital-acquired compared with immunocompetent patients. No difference existed in grade of anatomical disruption, disease severity, organ failure, pathogens, and resistance patterns. Septic shock was significantly more frequent in the immunocompromised population. Mortality was similar in both groups (31.1% vs. 28.9 %; p = 0.468). Immunocompromise was not a risk factor for mortality (OR 0.98, 95 % CI 0.66–1.43). Independent risk factors for mortality among immunocompromised patients included septic shock at presentation (OR 6.64, 95 % CI 1.27–55.72), and unsuccessful source control with persistent inflammation (OR 5.48, 95 % CI 2.29–12.57). In immunocompromised ICU patients with IAI, short-term mortality was similar to immunocompetent patients, despite the former presented more frequently with septic shock, and septic shock and persistent inflammation after source control were independent risk factors for death. [ABSTRACT FROM AUTHOR]

Intra-abdominal infections (IAIs) account for a major cause of morbidity and mortality, representing the second most common sepsis-related death with a hospital mortality of 23–38%. Prompt identification of sepsis source, appropriate resuscitation, and early treatment with the shortest delay possible are the cornerstones of management of IAIs and are associated with a more favorable clinical outcome. The aim of source control is to reduce microbial load by removing the infection source and it is achievable by using a wide range of procedures, such as definitive surgical removal of anatomic infectious foci, percutaneous drainage and toilette of infected collections, decompression, and debridement of infected and necrotic tissue or device removal, providing for the restoration of anatomy and function. Damage control surgery may be an option in selected septic patients. Intra-abdominal infections can be classified as uncomplicated or complicated causing localized or diffuse peritonitis. Early clinical evaluation is mandatory in order to optimize diagnostic testing and establish a therapeutic plan. Prognostic scores could serve as helpful tools in medical settings for evaluating both the seriousness and future outlook of a condition. The patient's conditions and the potential progression of the disease determine when to initiate source control. Patients can be classified into three groups based on disease severity, the origin of infection, and the patient's overall physical health, as well as any existing comorbidities. In recent decades, antibiotic resistance has become a global health threat caused by inappropriate antibiotic regimens, inadequate control measures, and infection prevention. The sepsis prevention and infection control protocols combined with optimizing antibiotic administration are crucial to improve outcome and should be encouraged in surgical departments. Antibiotic and antifungal regimens in patients with IAIs should be based on the resistance epidemiology, clinical conditions, and risk for multidrug resistance (MDR) and Candida spp. infections. Several challenges still exist regarding the effectiveness, timing, and patient stratification, as well as the procedures for source control. Antibiotic choice, optimal dosing, and duration of therapy are essential to achieve the best treatment. Promoting standard of care in the management of IAIs improves clinical outcomes worldwide. Further trials and stronger evidence are required to achieve optimal management with the least morbidity in the clinical care of critically ill patients with intra-abdominal sepsis. [ABSTRACT FROM AUTHOR]

Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs. [ABSTRACT FROM AUTHOR]

This article presents a comparative study on the outcomes of secondary peritonitis in different regions of India using the Mannheim peritonitis index (MPI). The study found that factors such as age, gender, and site of perforation were correlated with mortality rates. The study suggests that the MPI scoring system is effective in predicting risk and recommends aggressive resuscitation and intensive care support for patients with a high MPI score. The article also discusses the prevalence of upper gastrointestinal tract perforations in the Indian population and the importance of early presentation and proper management. [Extracted from the article]

This comprehensive review aims to provide a practical guide for intensivists, focusing on enhancing patient care associated with nosocomial peritonitis (NP). It explores the epidemiology, diagnosis, and management of NP, a significant contributor to the mortality of surgical patients worldwide. NP is, per definition, a hospital-acquired condition and a consequence of gastrointestinal surgery or a complication of other diseases. NP, one of the most prevalent causes of sepsis in surgical Intensive Care Units (ICUs), is often associated with multi-drug resistant (MDR) bacteria and high mortality rates. Early clinical suspicion and the utilization of various diagnostic tools like biomarkers and imaging are of great importance. Microbiology is often complex, with antimicrobial resistance escalating in many parts of the world. Fungal peritonitis and its risk factors, diagnostic hurdles, and effective management approaches are particularly relevant in patients with NP. Contemporary antimicrobial strategies for treating NP are discussed, including drug resistance challenges and empirical antibiotic regimens. The importance of source control in intra-abdominal infection management, including surgical and non-surgical interventions, is also emphasized. A deeper exploration into the role of open abdomen treatment as a potential option for selected patients is proposed, indicating an area for further investigation. This review underscores the need for more research to advance the best treatment strategies for NP. [ABSTRACT FROM AUTHOR]

Intra-abdominal infections (IAIs) account for a major cause of morbidity and mortality, representing the second most common sepsis-related death with a hospital mortality of 23–38%. Prompt identification of sepsis source, appropriate resuscitation, and early treatment with the shortest delay possible are the cornerstones of management of IAIs and are associated with a more favorable clinical outcome. The aim of source control is to reduce microbial load by removing the infection source and it is achievable by using a wide range of procedures, such as definitive surgical removal of anatomic infectious foci, percutaneous drainage and toilette of infected collections, decompression, and debridement of infected and necrotic tissue or device removal, providing for the restoration of anatomy and function. Damage control surgery may be an option in selected septic patients. Intra-abdominal infections can be classified as uncomplicated or complicated causing localized or diffuse peritonitis. Early clinical evaluation is mandatory in order to optimize diagnostic testing and establish a therapeutic plan. Prognostic scores could serve as helpful tools in medical settings for evaluating both the seriousness and future outlook of a condition. The patient’s conditions and the potential progression of the disease determine when to initiate source control. Patients can be classified into three groups based on disease severity, the origin of infection, and the patient’s overall physical health, as well as any existing comorbidities. In recent decades, antibiotic resistance has become a global health threat caused by inappropriate antibiotic regimens, inadequate control measures, and infection prevention. The sepsis prevention and infection control protocols combined with optimizing antibiotic administration are crucial to improve outcome and should be encouraged in surgical departments. Antibiotic and antifungal regimens in patients with IAIs should be based on the resistance epidemiology, clinical conditions, and risk for multidrug resistance (MDR) and Candida spp. infections. Several challenges still exist regarding the effectiveness, timing, and patient stratification, as well as the procedures for source control. Antibiotic choice, optimal dosing, and duration of therapy are essential to achieve the best treatment. Promoting standard of care in the management of IAIs improves clinical outcomes worldwide. Further trials and stronger evidence are required to achieve optimal management with the least morbidity in the clinical care of critically ill patients with intra-abdominal sepsis.

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Introduction: A common feature of external duodenal fistulae is the devastating effect of the duodenal content rich in bile and pancreatic juice on nearby tissues with therapy-resistant local and systemic complications. This study analyzes the results of different management options with emphasis on successful fistula closure rates. Methods: A retrospective single academic center study of adult patients treated for complex duodenal fistulas over a 17-year period with descriptive and univariate analyses was performed. Results: Fifty patients were identified. First line treatment was surgical in 38 (76%) cases and consisted of resuture or resection with anastomosis combined with duodenal decompression and periduodenal drainage in 36 cases, rectus muscle patch, and surgical decompression with T-tube in one each. Fistula closure rate was 29/38 (76%). In 12 cases, the initial management was nonoperative with or without percutaneous drainage. The fistula was closed without surgery in 5/6 patients (1 patient died with persistent fistula). Among the remaining 6 patients eventually operated, fistula closure was achieved in 4 cases. There was no difference in successful fistula closure rates among initially operatively versus nonoperatively managed patients (29/38 vs. 9/12, p = 1.000). However, when considering eventually failed nonoperative management in 7/12 patients, there was a significant difference in the fistula closure rate (29/38 vs. 5/12, p = 0.036). The overall in-hospital mortality rate was 20/50 (40%). Conclusions: Surgical closure combined with duodenal decompression in complex duodenal leaks offers the best chance of successful outcome. In selected cases, nonoperative management can be tried, accepting that some patients may require surgery later. [ABSTRACT FROM AUTHOR]

Background: Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) (https://clinicaltrials.gov/ct2/show/NCT03163095). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. Methods: The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. Discussion: OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. Trial registration: National Institutes of Health (https://clinicaltrials.gov/ct2/show/NCT03163095). [ABSTRACT FROM AUTHOR]

Objectives: Studies have shown the feasibility of short-course antimicrobials in complicated intraabdominal infection (CIAI) following source control procedure (SCP). This study aimed to compare postoperative complication rates in short-course (5 days) and conventional (7-10 days) duration groups after antimicrobial therapy. Methods: This was a single-centre, open-labelled, randomised controlled trial conducted in Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, from July 2017 to December 2019 on patients with CIAI. Patients who were haemodynamically unstable, pregnant and had non-perforated, non-gangrenous appendicitis or cholecystitis were excluded. Primary endpoints were surgical site infection (SSI), recurrent intraabdominal infection (IAI) and mortality. Secondary endpoints included time till occurrence of composite primary outcomes, duration of antimicrobial therapy, the length of hospital stays, antimicrobial-free interval, hospital-free days at 30 day intervals and the presence of extra-abdominal infections. Results: Overall, 140 patients were included whose demographic and clinico-pathological details were comparable in both groups. There was no difference in SSI (37% versus 35.6%) and recurrent IAI (5.7% versus 2.8%; P = 0.76); no mortality was observed in either groups. The composite primary outcome (37% versus 35.7%) was also similar in both groups. Secondary outcomes included the duration of antimicrobial therapy (5 versus 8 days; P <0.001) and length of hospitalisation (5 versus 7 days; P = 0.014) were significant. Times till occurrence of SSI and recurrent IAI, incidence of extra-abdominal infection and resistant pathogens were comparable. Conclusion: Short-course antimicrobial therapy for 5 days following SCP for mild and moderate CIAI was comparable to conventional duration antimicrobial therapy, indicating similar efficacy. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Intraoperative peritoneal lavage (IOPL) with saline has been widely used in surgical practice. However, the effectiveness of IOPL with saline in patients with intra-abdominal infections (IAIs) remains controversial. This study aims to systematically review randomized controlled trials (RCTs) evaluating the effectiveness of IOPL in patients with IAIs. Methods: The databases of PubMed, Embase, Web of Science, Cochrane library, CNKI, WanFang, and CBM databases were searched from inception to December 31, 2022. Random-effects models were used to calculate the risk ratio (RR), mean difference, and standardized mean difference. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to rate the quality of the evidence. Results: Ten RCTs with 1318 participants were included, of which eight studies on appendicitis and two studies on peritonitis. Moderate-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (0% vs. 1.1%; RR, 0.31 [95% CI, 0.02–6.39]), intra-abdominal abscess (12.3% vs. 11.8%; RR, 1.02 [95% CI, 0.70–1.48]; I2 = 24%), incisional surgical site infections (3.3% vs. 3.8%; RR, 0.72 [95% CI, 0.18–2.86]; I2 = 50%), postoperative complication (11.0% vs. 13.2%; RR, 0.74 [95% CI, 0.39–1.41]; I2 = 64%), reoperation (2.9% vs. 1.7%; RR,1.71 [95% CI, 0.74–3.93]; I2 = 0%) and readmission (5.2% vs. 6.6%; RR, 0.95 [95% CI, 0.48–1.87]; I2 = 7%) in patients with appendicitis when compared to non-IOPL. Low-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (22.7% vs. 23.3%; RR, 0.97 [95% CI, 0.45–2.09], I2 = 0%) and intra-abdominal abscess (5.1% vs. 5.0%; RR, 1.05 [95% CI, 0.16–6.98], I2 = 0%) in patients with peritonitis when compared to non-IOPL. Conclusion: IOPL with saline use in patients with appendicitis was not associated with significantly decreased risk of mortality, intra-abdominal abscess, incisional surgical site infection, postoperative complication, reoperation, and readmission compared with non-IOPL. These findings do not support the routine use of IOPL with saline in patients with appendicitis. The benefits of IOPL for IAI caused by other types of abdominal infections need to be investigated. [ABSTRACT FROM AUTHOR]

Simple Summary: Sepsis is the leading cause of morbidity and mortality worldwide. It reflects a deficiency in the interplay between the innate and adaptive immune response and leads to an injury of the body's own tissue with dramatic and long-lasting consequences for the patient. However, understanding the immunological background of peritonitis and abdominal sepsis together with its molecular pathomechanism still remains elusive, leading to limited therapeutic options. The TNF-related apoptosis-inducing ligand (TRAIL) has already been shown to induce neutrophil apoptosis and enhance survival in a murine sepsis model. In the present work, we investigated how neutrophil granulocytes regulate their sensitivity to TRAIL-induced apoptosis during the course of sepsis. Despite intensive scientific efforts, the therapy of peritonitis is presently limited to symptomatic measures, including infectious source control and broad-spectrum antibiotics. Promising therapeutic approaches to reduce morbidity and mortality are still missing. Within the early phase of abdominal sepsis, apoptosis of neutrophil granulocytes is inhibited, which is linked to tissue damage and septic shock. TNF-related apoptosis-inducing ligand (TRAIL) is a promising agent to stimulate neutrophil apoptosis. However, the underlying mechanisms have not been elucidated so far. The objective of the present study was to characterize the molecular mechanisms of TRAIL-stimulated apoptosis in early abdominal sepsis. Therefore, the murine sepsis model Colon ascendens stent peritonitis (CASP) was applied in wild type (WT) and TRAIL knock-out (TRAIL–/–) C57/BL6j mice. Neutrophil granulocytes were isolated from spleen, blood, bone marrow, and peritoneal lavage using magnetic-activated cell sorting. Neutrophil maturation was analyzed by light microscopy, and apoptotic neutrophils were quantified by fluorescence-activated cell sorting (FACS). Western blot and FACS were used to investigate expression changes in apoptotic proteins and TRAIL receptors. The impact of TRAIL-induced apoptosis was studied in vitro. In septic mice (CASP 6 h), the number of neutrophils in the BM was reduced but increased in the blood and peritoneal lavage. This was paralleled by an increased maturation of neutrophils from rod-shaped to segmented neutrophils (right shift). In vitro, extrinsic TRAIL stimulation did not alter the apoptosis level of naïve neutrophils but stimulated apoptosis in neutrophils derived from septic WT and TRAIL–/– mice. Neutrophils of the bone marrow and spleen showed enhanced protein expression of anti-apoptotic Flip, c-IAP1, and McL-1 and reduced expression levels of pro-apoptotic Bax in neutrophils, which might correlate with apoptosis inhibition in these cells. CASP increased the expression of intrinsic TRAIL in neutrophils derived from the bone marrow and spleen. This might be explained by an increased expression of the TRAIL receptors DR5, DcR1, and DcR2 on neutrophils in sepsis. No differences were observed between septic or naïve WT and TRAIL–/– mice. In conclusion, the present study shows that neutrophil granulocytes are sensitive to TRAIL-stimulated apoptosis in the early stage of abdominal sepsis, emphasizing the promising role of TRAIL as a therapeutic agent. [ABSTRACT FROM AUTHOR]

Despite its numerous benefits, peritoneal dialysis (PD) can rarely result in dangerous and even life-threatening complications, including peritonitis, hernias, encapsulating peritoneal sclerosis (EPS), and rarely peritoneal pseudocysts. Herein, we present a rare case of a giant intra-peritoneal pseudocyst that presented four months following the discontinuation of a 5-year course of complicated PD. Despite the initially successful drainages, the patient's symptoms continued to recur, and the imaging findings were concerning for underlying neoplastic processes. As such, a staged surgical approach was performed, starting with a diagnostic laparoscopy and was subsequently followed with cyst excision and marsupialization to the peritoneal cavity. While previous reports of such rare pseudocyst have been documented in the literature as a complication of PD, to our knowledge, this is the second case of pseudocyst formation to occur months after the discontinuation of PD therapy. This case emphasizes the importance of close follow-up in PD patients and showcases how a staged surgical approach can be utilized to accurately diagnose and manage such complicated cases. [ABSTRACT FROM AUTHOR]

Background: Hemodynamic instability in cirrhotic individuals and the onset of bacterial infection are both linked to elevated levels of Lipopolysaccharide binding protein (LBP). Objective: The aim of the current work was to evaluate the significance of lipopolysaccharide binding protein (LBP) level in serum and ascitic fluid in spontaneous bacterial peritonitis (SBP) patients as a marker for infection. Patients and Methods:A total of 112 patients were enrolled in this case control study and were split into two categories: Group (A):consisted of 56 individuals with chronic liver disease (CLD) having ascites exacerbated by spontaneous bacterial peritonitis (SBP) through clinical and laboratory examinations. Group (B): consisted of 56 individuals with chronic liver disease (CLD) and ascites who had no detectable infection based on clinical and laboratory tests. Results: In group A; significant positive correlations were found between serum LBP, HB, and total protein. Also, a negative remarkable correlation between serum LBP, INR, PTT, PT, serum creatinine, direct bilirubin, total bilirubin, PLT, and ascitic fluid LBP. In group (B);significant positive correlations were found between serum LBP, AST, and TLC. Also, a negative remarkable correlation between serum LBP, PTT, serum urea, serum creatinine, and total bilirubin. Conclusion: It could be concluded that serum LBP demonstrated a highly significant difference between the two groups with a substantial difference as regard the diagnosis of spontaneous bacterial peritonitis, both in terms of sensitivity and specificity. Serum LBP may be considered as a diagnostic tool for SBP in cirrhotic patients with ascites. [ABSTRACT FROM AUTHOR]

Introduction: Recently, complicated intra-abdominal infections (cIAI) have been caused not only by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, and Pseudomonas aeruginosa, but also by extended-spectrum β-lactamase-producing Enterobacterales members. Ceftolozane–tazobactam (CTLZ–TAZ) is considered to exhibit therapeutic effects against cIAI. Studies on the concentrations of antibiotics in abdominal tissues directly affected by cIAI are limited. Therefore, in this study, we investigated the pharmacokinetics of CTLZ–TAZ in abdominal tissue and simulated the administration regimen required to achieve the pharmacodynamic target for cIAI-causing bacteria. Methods: Patients scheduled for elective lower gastrointestinal surgery were intravenously administered preoperative CTLZ–TAZ (1 g CTLZ and 0.5 g TAZ). Plasma, peritoneal fluid, peritoneum, and subcutaneous adipose tissue samples were collected during the surgery, and CTLZ as well as TAZ concentrations were measured. The noncompartmental and compartmental pharmacokinetic parameters were then estimated. Site-specific pharmacodynamic target attainment analysis using 1.5 g of CTLZ–TAZ was performed. Results: CTLZ–TAZ was administered to nine patients (once to five patients and twice to four patients). The mean peritoneal fluid-to-plasma ratio (one dose/two doses) for CTLZ was 0.74/1.15, which was slightly higher than the mean peritoneal fluid-to-plasma ratio for TAZ (0.95/1.13). The ratio for subcutaneous adipose was lower than those for peritoneal fluid and peritoneum tissues. We also discovered that the average ratio of CTLZ and TAZ concentrations in all tissues was maintained at or above 2:1. In our investigation of pharmacodynamic target attainment in each tissue, the desired bactericidal effect was attained with all CTLZ–TAZ (1.5 g) administration regimens [q12h (3 g/day), q8h (4.5 g/day), and q6h (6 g/day)]. Conclusion: To the best of our knowledge, this is the first study investigating the optimal pharmacodynamic level of CTLZ–TAZ in the abdominal tissue against cIAI-causing bacteria. This study also serves as a guideline for designing an optimal administration regimen based on pharmacodynamic target attainment for cIAI-causing bacteria. Details of the trial registration: The institutional review board of Hiroshima University Hospital, CRB6180006. The Japan Registry of Clinical Trials, jRCTs061190025. [ABSTRACT FROM AUTHOR]

Background: Intra-abdominal infection (IAI) results in prolonged in-hospital length-of-stay, critical care unit requirements, and multiple surgical procedures. Several antimicrobial agents are available for treatment of IAI. In Colombia, there are no data on the comparative effectiveness of the different regimens used. Patients and Methods: A multicenter retrospective cohort study was completed in four third-level hospitals by comparing treatment effectiveness of five different antibiotic protocols (ampicillin-sulbactam, clindamycin-amikacin, piperacillin-tazobactam, amikacin-metronidazole, and cefuroxime-metronidazole) in patients with a diagnosis of IAI. Analysis was based on a composed outcome of therapeutic failure (change of antibiotic because of no clinical improvement, requirement of surgical re-intervention, post-operative infection, change of antibiotic because of antimicrobial resistance, and in-hospital mortality). Association of each antibiotic protocol to therapeutic failure was assessed through logistic regression analysis. Results: Five hundred ninety-three individuals were included. Two hundred twenty-nine were prescribed ampicillin-sulbactam; 170, clindamycin-amikacin; 77, amikacin-metronidazole; 83, piperacillin-tazobactam; and 34, cefuroxime-metronidazole. Therapeutic failure rate was 22%. Multivariable analysis showed none of the evaluated antibiotic protocols had an association with the primary outcome. Variables having an association for higher risk were age >70 years old (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.04-4.18); complicated IAI (OR, 3.36; 95% CI, 1.4-8.07); and World Society of Emergency Surgery (WSES) Sepsis Severity Score (OR, 1.31; 95% CI, 1.18-1.45). Adequate source control (OR, 0.16; 95% CI, 0.05-0.45) and hospitalization at Health Center 2 (OR, 0.30; 95% CI, 0.14-0.63) were identified as protective factors. Conclusions: There are no differences between the rate of therapeutic failure among the different antibiotic protocols evaluated. This outcome depends heavily on risk factors related to disease severity when surgical intervention occurs. [ABSTRACT FROM AUTHOR]

Spontaneous bacterial peritonitis is a known complication of patients with decompensated cirrhosis and ascites. It is differentiated from secondary bacterial peritonitis by the absence of an intraabdominal source of infection. We present a 56-year-old man with alcoholic cirrhosis who underwent multiple paracenteses that yielded fluid with progressively increasing neutrophil counts and several different organisms, recurring despite numerous treatments for SBP. Eventually, a computed tomography (CT) of the abdomen and the pelvis revealed a large intraabdominal abscess (22 × 13 cm) treated with an ultrasound-guided drain and IV antibiotics. Recurrent episodes of SBP despite appropriate antibiotics should raise suspicion for secondary bacterial peritonitis. It is crucial to differentiate SBP from secondary bacterial peritonitis as the mortality of the latter is much higher without prompt treatment. Appropriate antibiotic regimens, prompt surgical treatment, and postoperative care are crucial to improving clinical outcomes in these patients. [ABSTRACT FROM AUTHOR]

This comprehensive review of the recently published literature offers an overview of a very topical and complex healthcare problem: secondary peritonitis from multidrug-resistant pathogens, especially carbapenem-resistant Enterobacterales (CRE). Spontaneous secondary peritonitis and postsurgical secondary peritonitis are among the major causes of community- and healthcare- acquired sepsis, respectively. A large number of patients enter ICUs with a diagnosis of secondary peritonitis, and a high number of them reveal infection by CRE, P. aeruginosa or A. baumannii. For this reason, we conceived the idea to create a synthetic report on this topic including updated epidemiology data, a description of CRE resistance patterns, current strategies of antimicrobial treatment, and future perspectives. From this update it is clear that antimicrobial stewardship and precision medicine are becoming essential to fight the emergence of antimicrobial resistance and that even if there are new drugs effective against CRE causing secondary peritonitis, these drugs have to be used carefully especially in empirical therapy. [ABSTRACT FROM AUTHOR]

Abstract Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Intra-abdominal infections (IAIs) are a common cause of sepsis, and frequently occur in intensive care unit (ICU) patients. IAIs include many diagnoses, including peritonitis, cholangitis, diverticulitis, pancreatitis, abdominal abscess, intestinal perforation, abdominal trauma, and pelvic inflammatory disease. IAIs are the second most common cause of infectious morbidity and mortality in the ICU after pneumonia. IAIs are also the second most common cause of sepsis in critically ill patients, and affect approximately 5% of ICU patients. Mortality with IAI in ICU patients ranges from 5 to 50%, with the wide variability related to the specific IAI present, associated patient comorbidities, severity of illness, and organ dysfunction and failures. It is important to have a comprehensive understanding of IAIs as potential causes of life-threatening infections in ICU patients to provide the best diagnostic and therapeutic care for optimal patient outcomes in the ICU. [ABSTRACT FROM AUTHOR]

Disseminated Pasteurella multocida infection is rare and usually occurs in patients who are immunocompromised. Patients with liver cirrhosis seem to be particularly vulnerable; potentially related to cirrhosis associated immune dysfunction syndrome, frequently present in this population. While many patients report pet cat or dog bites or scratches, some patients develop infection even without obvious exposure, just from being in contact with animals. We present a patient with cellulitis and spontaneous bacterial peritonitis by Pasteurella multocida in whom infection disseminated and the patient developed bacteremia that seeded in the right acromioclavicular joint. We hypothesize that the port of entry for infection in our patient was contact with a pet cat through a chronic open leg wound. The patient was treated with intravenous ceftriaxone 2 g daily for 6 weeks and attained complete recovery.

The diagnosis of intra-abdominal infection and post-operative peritonitis based on clinical examination, biomarkers and radiological signs, should be made as early as possible to improve outcomes and decrease mortality through early and optimal source control, adequate surgery and appropriate antibiotic therapy (Montravers et al. Therapeutic management of peritonitis: a comprehensive guide for intensivists. Intensive Care Med 2016; 42 :1234–47). However, the indication and the timing of the surgery is often not an easy decision. This case presents the use of a novel early biomarker of infection and sepsis, pancreatic stone protein (Fidalgo et al. Pancreatic stone protein: review of a new biomarker in sepsis. J Clin Med 2022; 11 :1085), as a tool to aid in the diagnosis of intra-abdominal infection and post-operative peritonitis and to help guide the decision for adequate surgeries in a patient with intra-abdominal infection and post radical prostatectomy peritonitis. [ABSTRACT FROM AUTHOR]

Background:Pseudomonas aeruginosa is isolated at variable rates from intra-abdominal infections (IAI). Not all recommended empiric regimens for IAI include anti-Pseudomonas aeruginosa activity, for example, ceftriaxone and metronidazole. We hypothesized that within an adult population, Pseudomonas aeruginosa is a relatively rare isolate and has no association with mortality, and thus, empiric therapy with anti-Pseudomonas aeruginosa activity is not warranted. Patients and Methods: All IAI with positive cultures treated between 1997 and 2017 at a single institution were analyzed. This data set was divided into two cohorts, namely, those with cultures positive for Pseudomonas aeruginosa and those without. Demographics and in-hospital mortality were compared by Student t-test and χ2 analysis. Predictors of isolation of Pseudomonas aeruginosa and in-hospital mortality were done by logistic regression (LR) analysis. Results: In total, 2,420 IAIs were identified, 104 (4.3%) with Pseudomonas aeruginosa and 2,316 (95.7%) without. Major demographic differences between patients with Pseudomonas aeruginosa and those without included a higher rate of health-care-associated infections (87/104, 83.7% vs. 621/2316, 26.8%; p = 0.02), a higher rate of intensive care unit (ICU)-acquired infections (23/104, 22.1% vs. 329/2316, 14.2%; p = 0.04) and a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (17.7 ± 0.8 vs. 14.5 ± 0.2; p < 0.0001). There was an increased rate of Pseudomonas aeruginosa isolation with increasing APACHE II score. Independent predictors of isolation of Pseudomonas aeruginosa by LR included APACHE II score and days of hospitalization prior to diagnosis. Crude in-hospital mortality was similar between groups: Pseudomonas aeruginosa 14/104 (13.5%) and 276/2316 (11.9%), p = 0.79. After controlling for age, gender, APACHE II, prior transfusion, immunosuppression status, solid organ transplant status, healthcare-association, and days of hospitalization prior to diagnosis, the isolation of Pseudomonas aeruginosa was not associated with mortality. Conclusion:Pseudomonas aeruginosa is infrequently isolated and overall not associated with mortality. Nonetheless, there may be a population that merits empiric anti-Pseudomonas aeruginosa therapy: those with APACHE II ≥20 or a significant length of hospitalization prior to diagnosis. [ABSTRACT FROM AUTHOR]

Background: Knowledge of resistance patterns is essential to choose empirical treatment. We aimed to determine the risk factors for antibiotic-resistant microorganisms (ARM) in intraabdominal infections (IAI) and their impact on mortality. Methods: Retrospective cohort study of patients with bacteremia from IAI origin in a single hospital between January 2006 and July 2017. Results: A total of 1485 episodes were recorded, including 381 (25.6%) due to ARM. Independent predictors of ARM were cirrhosis (OR 2; [95% CI 1.15–3.48]), immunosuppression (OR 1.49; 1.12–1.97), prior ceftazidime exposure (OR 3.7; 1.14–11.9), number of prior antibiotics (OR 2.33; 1.61–3.35 for 1 antibiotic), biliary manipulation (OR 1.53; 1.02–2.96), hospital-acquisition (OR 2.77; 1.89–4) and shock (OR 1.48; 1.07–2). Mortality rate of the whole cohort was 11.1%. Age (OR 1.03; 1.01–1.04), cirrhosis (OR 2.32; 1.07–4.38), urinary catheter (OR 1.99; 1.17–3.38), ultimately (OR 2.28; 1.47–3.51) or rapidly (OR 13.3; 7.12–24.9) fatal underlying disease, nosocomial infection (OR 2.76; 1.6–4.75), peritonitis (OR 1.95, 1.1–3.45), absence of fever (OR 2.17; 1.25–3.77), shock (OR 5.96; 3.89–9.13), and an ARM in non-biliary infections (OR 2.14; 1.19–3.83) were independent predictors of 30-day mortality. Source control (OR 0.24; 0.13–0.44) and 2015–2017 period (OR 0.29; 0.14–0.6) were protective. Conclusion: Biliary manipulation and septic shock are predictors of ARM. The presence of an ARM from a non-biliary focus is a poor-prognosis indicator. Source control continues to be of paramount importance. [ABSTRACT FROM AUTHOR]

Peritoneal dialysis (PD)‐related peritonitis is sometimes complicated with other infections; however, few cases of splenic abscess have been reported. We present the case of a 64‐year‐old PD patient with complicated splenic abscesses diagnosed following relapsing sterile peritonitis. After PD induction, he presented with turbid peritoneal fluid and was diagnosed with PD‐related peritonitis. A plain abdominal computed tomography (CT) did not reveal any intra‐abdominal focus of infection. After empiric intravenous antibiotics, the peritoneal dialysate was initially cleared, with a decrease in dialysate white blood cells (WBC) to 20/µL. However, WBC and C‐reactive protein (CRP) levels remained elevated. A contrast‐enhanced abdominal CT showed two areas of low‐density fluid with no enhancement in a mildly enlarged spleen, making it difficult to distinguish abscesses from cysts. Due to relapsing sterile peritonitis, we performed an abdominal ultrasonography, and suspected splenic abscesses due to rapid increase in size. Repeated imaging tests were useful in establishing a diagnosis of splenic abscesses. Considering the persistent elevation of WBC and CRP levels, imaging findings, and episodes of relapsing peritonitis, we comprehensively formed the diagnosis, and performed a splenectomy as a rescue therapy. We should consider the possibility of other infectious foci with persistent inflammation after resolving PD‐related peritonitis. [ABSTRACT FROM AUTHOR]

Vacuum-assisted abdominal closure (VAAC) has evolved as a promising method for treatment of emergent surgical patients. The aim of the study was an assessment of the complication rate and outcomes following routine application of VAAC in a cohort of patients suffering predominantly with peritonitis of the lower gastrointestinal tract (GIT) origin. The prospectively collected data was analysed retrospectively, including demographic data, aetiological factors, comorbid conditions and severity of the disease. The indications for VAAC included complicated intra-abdominal infection, purulent peritonitis with sepsis and/or risk of increased intra-abdominal pressure. In total, 130 patients were managed with VAAC. The median age was 63.5 years, with a predominance of male patients (61.5%). Systemic inflammatory response was present in 68.5%, the median C-reactive protein (CRP) was 239.58 mg/l, Procalcitonin (PCT) level 7.02 ng/ml, and lactate 1.84 mmol/l before intervention. The median Sequential Organ Failure Assessment (SOFA) score was 4 and the Mannheim Peritonitis Index was 26. Sepsis developed in 87.0% of patients, and 43.8% had septic shock. VAAC was applied in 58.5% due to a perforation of the lower GIT, in 26.1% due to perforation of the upper GIT, and in 15.4% for other reasons. A median of two (interquartile range, IQR 1–3) VAAC system changes were performed in a period of 7 (IQR 4–11) days. In 88.6% of cases, multiple types of microorganisms were present. The application of VAAC resulted in a significant decrease of the postoperative SOFA score, and CRP, PCT and lactate levels (p < 0.001). The complications included a "frozen abdomen", enterocutaneous fistula, intraabdominal abscess and bleeding in 7.7%, 5.4% and 6.0% cases, respectively. Primary abdominal closure was accomplished in 76.2%, resulting in a 23.1% mortality rate. VAAC was found to be safe in the treatment of abdominal sepsis including in patients with faecal peritonitis. Complete abdominal closure can be achieved in the majority of patients resulting in a lower mortality rate. [ABSTRACT FROM AUTHOR]

Although the abilities of the omentum to alleviate inflammation and prevent infection have been revealed over the past decades, the underlying mechanisms remain largely unelucidated. Here, we demonstrated that the mortality of mice exposed to cecal ligation and puncture (CLP) and omentectomy was remarkably increased compared to those treated with CLP alone. Moreover, the efficacy of the omentum was associated with an impairment in intraperitoneal bacterial clearance together with an increase in the expression of proinflammatory cytokines. Besides, in response to peritoneal infections, the size and quantity of the omental milky spots (MSs) were increased tremendously and they also support innate-like B1 cell responses and local IgM production in the peritoneal cavity. Furthermore, not only the migration but also the functional activities of neutrophils were diminished in the absence of the omentum. These data collectively show that the omentum contributes more to peritoneal immune responses during septic peritonitis than has heretofore been recognized. Thus, harnessing the function of MS-containing omentum to increase its protective effectiveness may exert important biological and therapeutic implications for the control of intra-abdominal infections. [ABSTRACT FROM AUTHOR]

Intra-abdominal infection (peritonitis) is a leading cause of severe disease in surgical intensive care units, as over 70% of patients diagnosed with peritonitis develop septic shock. A critical role of the immune system is to return to homeostasis after combating infection. S100A8/A9 (calprotectin) is an antimicrobial and pro-inflammatory protein complex used as a biomarker for diagnosis of numerous inflammatory disorders. Here we describe the role of S100A8/A9 in inflammatory collateral tissue damage (ICTD). Using a mouse model of disseminated intra-abdominal candidiasis (IAC) in wild-type and S100A8/A9-deficient mice in the presence or absence of S100A9 inhibitor paquinimod, the role of S100A8/A9 during ICTD and fungal clearance were investigated. S100A8/A9-deficient mice developed less ICTD than wild-type mice. Restoration of S100A8/A9 in knockout mice by injection of recombinant protein resulted in increased ICTD and fungal clearance comparable to wild-type levels. Treatment with paquinimod abolished ICTD and S100A9-deficient mice showed increased survival compared to wild-type littermates. The data indicates that S100A8/A9 controls ICTD levels and antimicrobial activity during IAC and that targeting of S100A8/A9 could serve as promising adjunct therapy against this challenging disease. [ABSTRACT FROM AUTHOR]

Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann's procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure. [ABSTRACT FROM AUTHOR]

Ceftolozane/tazobactam is a new combined antibacterial agent for the treatment of infections caused by gram-negative microorganisms, P. aeruginosa in particular, including strains resistant to other clinically available antimicrobials. In this paper we reviewed the data on antimicrobial activity, pharmacokinetics, clinical efficacy and safety of ceftolozane/tazobactam, as well as its potential role for the treatment of complicated intra-abdominal infections and urinary tract infections.

Background: Intra-abdominal infections (IAIs) are a wide range of pathological conditions that affect all intra-abdominal tissues and organs. These include both inflammation of individual organs and any type of peritonitis (primary, secondary, tertiary), where the severity of the disease often depends on the spread of inflammation - local or diffuse peritonitis. Methods: In this article, we present a review and analysis of current definitions, classifications, and approaches in the diagnosis and treatment of intra-abdominal infections. Results and Conclusions: IAIs remain an important cause of morbidity and mortality in modern surgical practice worldwide. Early and accurate clinical diagnosis, adequate local control, appropriate antimicrobial therapy according to the patient's risk factors and infection, and prompt resuscitation in critically ill patients are the cornerstones of IAI management. The application of the principles of evidence-based medicine and the individual approach to patients is crucial for optimizing results. [ABSTRACT FROM AUTHOR]

Introduction: The concentrations of tissue factor (TF) and tissue factor pathway inhibitor (TFPI) in the peritoneal fluid and blood plasma in patients with peritonitis were examined. The fibrinogenesis of the peritoneal cavity is not well-known although it is regarded as the main cause of intraperitoneal adhesions and the complications that arise from this. Materials and methods: The study enrolled a group of 77 consecutive patients with peritonitis, 28 women and 49 men aged 18-79 years (with an average age of 45 ±18 years). The patients were divided into 2 subgroups: those with complications (n = 64) and those without (n = 13). Concentrations of TF and TFPI in the peritoneal fluid and blood plasma of patients were examined. Results: In the peritoneal fluid, patients with complications had a higher concentration of TF (p < 0.007), but a lower concentration of TFPI (p < 0.0006). In blood plasma, TF was higher but TFPI was lower (p < 0.00001 in both). The area under curve (AUC) for TF and TFPI was 0.763 and 0.93 respectively, the cut-off point was 809.08 pg/mL and 21.6 pg/mL, respectively. The positive predictive value (PPV) and negative predictive value (NPV) for TF was 68% and 75% and for TFPI, 80% and 85%, respectively. Conclusions: The data can be taken as an example of cross-linking between extravascular coagulation and intraperitoneal adhesions. On the basis of TF and TFPI, it is clearly illustrated that there is some connection between coagulation and peritoneal fibrinogenesis, which could be involved in the pathogenesis of many complications in abdominal surgery and also indicate therapeutic targets. [ABSTRACT FROM AUTHOR]

One of the urgent problems facing medical science is purulent infection. In pediatric surgery, it is often necessary to deal with the most severe forms of purulent infection, one of which is appendicular peritonitis, which accounts for 50-90% of all purulent peritonitis in children. The mortality rate remains very high and reaches 1.6-20%. In addition, purulent peritonitis causes a large number of severe intra-abdominal complications. At the same time, the course of complicated purulent peritonitis is much more severe and the mortality rate reaches 20-35%. One of the most serious complications after surgical interventions for appendicular peritonitis is adhesive intestinal obstruction, which is the cause of repeated surgical interventions. [ABSTRACT FROM AUTHOR]

Background Burst abdomen is a very serious postoperative complication associated with high morbidity and mortality. It has a significant effect on health care cost, for both the patients and the hospitals. Purpose The aim of this study was to assess the incidence and perioperative risk factors of burst abdomen in patients undergoing emergency midline laparotomy. Patients and methods A prospective cohort study was conducted on 250 patients who underwent midline laparotomy at Kasr Al-Ainy Hospital Emergency Department, Cairo University, from August 2017 until August 2018. Factors such as age, sex, BMI, substance abuse, previous laparotomy, malignancy, diabetes mellitus, ascites, albumin, renal functions, bilirubin, hemoglobin, intra-abdominal pathology, suture material, creation of stoma, postoperative chest infection, postoperative paralytic ileus, leakage, and wound infection were observed and analyzed. Results Incidence of burst abdomen was 12.4%. Wound infections (87.1 vs. 18.7%, P<0.001), anemia (48.4 vs. 5%, P<0.001), diabetes (41.9 vs. 10%, P 0.001), hypoalbuminemia (64.5 vs. 27.4%, P<0.001), previous laparotomy (29 vs. 2.7%, P<0.001), creation of stoma (48.8 vs. 18.7%, P<0.001), chest problems (51.6 vs. 15.1%, P<0.001), ascites (22.6 vs. 4.6%, P<0.001), leakage (38.7 vs. 0%, P<0.001), and peritonitis (71 vs. 45.7%, P<0.001) were statistically significant factors. Conclusion Important risk factors according to our study were wound infection, anemia, previous laparotomy, creation of stoma, hypoalbuminemia, ascites, diabetes, type of intra-abdominal pathology, with maximum incidences in peritonitis, postoperative cough, and postoperative leakage. Patient sex, age, associated morbidities such as jaundice and uremia, previous use of steroids, suture material used in closure, and postoperative paralytic ileus were not significant in our study. [ABSTRACT FROM AUTHOR]

Background Laparoscopic appendectomy (LA) is performed worldwide in the treatment of acute appendicitis (AP), even if complicated by localized peritonitis. However, the role of the LA in the treatment of AP complicated by generalized peritonitis (GP) is yet controversial. The present study aimed to highlight the efficacy and safety of the laparoscopic approach in AP complicated with GP. Settings This study took place in Mansura University Hospital, Faculty of Medicine. Patients and methods From September 2010 to May 2019, the patients were randomly assigned to undergo either an LA or exploratory open appendectomy (EOA). The demographics of the patient and preoperative parameters, including radiological evaluation, intraoperative finding, and postoperative complications, were evaluated. The follow-up period was 8 months to 2 years (mean: 18 months). Main outcomes The primary outcome of this study was early postoperative complications. Results A total of 120 patients, aged 38±11 years, were analyzed. Of these, 69 (57.5%) patients underwent LA, whereas two (2.9%) were converted to open surgery. All patients presented with diffuse peritonitis. The duration of operation was longer in the laparoscopic group than in the EOA group (P=0.001). No differences were detected in the preoperative patient comorbidities. The rate of postoperative surgical infection and intra-abdominal abscess was similar in the laparoscopic and EOA groups (P=0.3040 and 0.0754, respectively). However, the length of hospital stay was shorter in the laparoscopic group than that in the EOA group (P=0.001). Conclusions The laparoscopic approach for appendicitis complicated by GP is better than the open approach, and hence, it must be the first choice for surgery in the case of clear preoperative diagnosis. [ABSTRACT FROM AUTHOR]

Postoperative abdominal infections are an important and heterogeneous health challenge in intensive care units (ICU) and encompass postoperative infectious processes developing within the abdominal cavity that may be caused by either bacterial or fungal pathogens. In this narrative review, we discuss postoperative bacterial and fungal abdominal infections, covering also multidrug-resistant (MDR) pathogens. We also cover clinically preeminent aspects such as the definition of postoperative abdominal infections, which still remains difficult owing to their heterogeneity in patient characteristics, clinical presentation, ecology and antimicrobial treatment. With regard to treatment, modifiable factors such as source control and antimicrobial therapy play a key role in influencing the prognosis of postoperative abdominal infections, but several conditions may hamper their correct application; thus efforts should necessarily be devoted towards improving their appropriateness and timing. Hot topics regarding the characteristics and management of postoperative abdominal infections are discussed in this narrative review. [ABSTRACT FROM AUTHOR]

Introduction. Achromobacter species (spp.) peritonitis has seldom been identified in medical literature. Scarce cases of Achromobacter peritonitis described previously have been correlated with peritoneal dialysis and more sparingly with spontaneous bacterial peritonitis. Achromobacter exhibits intrinsic and acquired resistance, especially in chronic infections, to most antibiotics. This article conducts a literature review of all previously reported Achromobacter spp. peritonitis and describes the first reported case of Achromobacter peritonitis as a complication of percutaneous endoscopic gastrostomy (PEG) tube placement. Discussion. Achromobacter peritonitis as a complication of PEG-tube placement has not been previously reported. In our patients' case, the recently placed PEG-tube with ascitic fluid leakage was identified as the most plausible infection source. Although a rare bacterial peritonitis pathogen, Achromobacter may be associated with wide antimicrobial resistance and unfavorable outcomes. Conclusion. No current guidelines provide significant guidance on treatment of PEG-tube peritonitis regardless of microbial etiology. Infectious Disease Society of America identifies various broad-spectrum antibiotics targeting nosocomial intra-abdominal coverage; some of these antimicrobial selections (such as cefepime and metronidazole combination) may yet be inadequate for widely resistant Achromobacter spp. Recognizably, the common antibiotics utilized for spontaneous bacterial peritonitis, i.e., third generation cephalosporins and fluoroquinolones, to which Achromobacter is resistant and variably susceptible, respectively, would be extensively insufficient. Piperacillin/tazobactam (P/T) and carbapenem were identified to provide the most reliable coverage in vitro; clinically, 5 out of the 8 patients who received either P/T or a carbapenem, or both, eventually experienced clinical improvement. [ABSTRACT FROM AUTHOR]

Introduction. The acute peritonitis is defined as the aggressive and diffuse inflammation of the peritoneum, of bacterial or chemical origin. Classification of peritonitis: primary, secondary (most common) and tertiary. Secondary peritonitis prognosis depends on: etiology, how fast the treatment is initiated, the age of the patient and the presence of associated pathologies. The objective of our study is to determine the frequency, epidemiological, clinical, paraclinical and etiological aspects of acute peritonitis and to evaluate the treatment quality in the Pediatric Surgery and Orthopedics Department of the Clinical Emergency Hospital for Children, Cluj-Napoca between October 2011 and October 2018.Material and methods: This study is a prospective one comprising 340 cases of acute localized or generalized peritonitis. The patients were hospitalized in the Pediatric Surgical Department of the Clinical Emergency Hospital for Children Cluj-Napoca, in a period of 4 years (October 2011 - October 2018).Inclusion criteria were represented by the clinical, imagistic and hematological documented peritonitis. Results: The most frequent cases of peritonitis were represented by appendicular peritonitis with an overwhelming proportion that agrees with literature data. On second place is the necrotizing enterocolitis. This is due to the addressability in the Pediatric Surgical Clinic on one hand and probably to the fact that premature patients are treated in county hospitals without logistic means or trained personnel. Posttraumatic peritonitis and peritonitis after peritoneal dialysis were on third place. Continuing our study we have observed that the post-operative peritonitis, pelviperitonitis, meconium peritonitis, peritonitis after Meckel diverticula, Crohn disease, intussusception, strangulated hernia, volvulus, perforated ulcer are much rarer. Based on where the lesion is located, the vast majority of peritonitis are originated from the submezocolical region and the most commonly perforated organ is the appendix. Discussion. In our study, the frequency of peritonitis was 12,4% of all surgical emergencies the average age was 7,8 years. Pain was the main symptom 191 of the patients having localized pain and 149 patients had diffuse pain. Vomiting was reported in 231(68%) patients and constipation or diarrhea in 83(24,4) patients. Regarding physical signs fever was present in 235 patient representing 69,11% of all patients. Abdominal ultrasound and plain abdominal X-ray were the main imagistic methods of investigations. Preoperative resuscitation is paramount in the treatment of peritonitis in children. Analgesia, nutritional support and sometimes even transfusion are critical in the treatment result improvement. Percutaneous drainage is an option in localized fluid collections but in generalized peritonitis abdominal lavage with warm saline a drainage are always indicated. In our study we noticed that most of the patients in which we used targeted lavage with a rectal tube, the rate of complications improved. Basically we used a small rectal tube (10-16 Fr) which we oriented in all intraabdominal zones with difficult access like pelvic regions, sub hepatic and sub diaphragmatic regions. We used a Guyon syringe to wash the abdominal cavity trough the rectal tube. This proved to be very efficient in avoiding infectious and obstructive complications. in intraabdominal infections. It is given daily in one dose and it is a good therapeutic option for patients that are allergic to penicillin and beta-lactam antibiotics. Moxifloxacin does not require dose adjustment in patients with impaired renal function, giving clinicians a monotherapeutic option in the treatment of complicated IAI. Conclusions: The patient with generalized acute peritonitis corresponds to a particular epidemiological profile related to: low socio-economical level, young age, male gender and pathological background. [ABSTRACT FROM AUTHOR]

Background: Critically ill patients with severe intra-abdominal infections (IAIs) requiring surgery may undergo several pharmacokinetic (PK) alterations that can lead to β-lactam underdosage.Objectives: To measure serum and peritoneal exudate concentrations of β-lactams after high doses and optimal administration schemes.Methods: This observational prospective study included critically ill patients with suspicion of IAI who required surgery and a β-lactam antibiotic as empirical therapy. Serum and peritoneal exudate concentrations were measured during surgery and after a 24 h steady-state period. The PK/pharmacodynamic (PD) target was to obtain serum β-lactam concentrations of 100% fT>4×MIC based on a worst-case scenario (based on the EUCAST highest epidemiological cut-off values) before bacterial documentation (a priori) and redefined following determination of the MIC for the isolated bacteria (a posteriori). Registered with ClinicalTrials.gov (NCT03310606).Results: Forty-eight patients were included with a median (IQR) age of 64 (53-74) years and a SAPS II of 40 (32-65). The main diagnosis was secondary nosocomial peritonitis. Piperacillin/tazobactam was the most administered β-lactam antibiotic (75%). The serum/peritoneal piperacillin/tazobactam ratio was 0.88 (0.64-0.97) after a 24 h steady-state period. Prior to bacterial documentation, 16 patients (33.3%) achieved the a priori PK/PD target. The identification of microorganisms was available for 34 patients (71%). Based on the MIC for isolated bacteria, 78% of the patients achieved the serum PK/PD target.Conclusions: In severe IAIs, high doses of β-lactams ensured 100% fT>4×MIC in the serum for 78% of critically ill patients with severe IAIs within the first 24 h. In order to define optimal β-lactam dosing, the PK/PD target should take into account the tissue penetration and local ecology. [ABSTRACT FROM AUTHOR]

Purpose: To describe the epidemiology of intra-abdominal infection in an international cohort of ICU patients according to a new system that classifies cases according to setting of infection acquisition (community-acquired, early onset hospital-acquired, and late-onset hospital-acquired), anatomical disruption (absent or present with localized or diffuse peritonitis), and severity of disease expression (infection, sepsis, and septic shock).Methods: We performed a multicenter (n = 309), observational, epidemiological study including adult ICU patients diagnosed with intra-abdominal infection. Risk factors for mortality were assessed by logistic regression analysis.Results: The cohort included 2621 patients. Setting of infection acquisition was community-acquired in 31.6%, early onset hospital-acquired in 25%, and late-onset hospital-acquired in 43.4% of patients. Overall prevalence of antimicrobial resistance was 26.3% and difficult-to-treat resistant Gram-negative bacteria 4.3%, with great variation according to geographic region. No difference in prevalence of antimicrobial resistance was observed according to setting of infection acquisition. Overall mortality was 29.1%. Independent risk factors for mortality included late-onset hospital-acquired infection, diffuse peritonitis, sepsis, septic shock, older age, malnutrition, liver failure, congestive heart failure, antimicrobial resistance (either methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum beta-lactamase-producing Gram-negative bacteria, or carbapenem-resistant Gram-negative bacteria) and source control failure evidenced by either the need for surgical revision or persistent inflammation.Conclusion: This multinational, heterogeneous cohort of ICU patients with intra-abdominal infection revealed that setting of infection acquisition, anatomical disruption, and severity of disease expression are disease-specific phenotypic characteristics associated with outcome, irrespective of the type of infection. Antimicrobial resistance is equally common in community-acquired as in hospital-acquired infection. [ABSTRACT FROM AUTHOR]

Abstract Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.