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We assessed the performance of PET/CT for diagnosis and management of infections in high-risk hematological cancer patients with persistent febrile neutropenia in a prospective study. (18)F-FDG PET/CT with contrast-enhanced CT was performed on day 5-7 of persistent fever. Between 2008 and 2011, 91 PET/CT examinations were performed for different episodes in 79 patients, resulting in 117 diagnoses. The sensitivity of the PET/CT was 79.8% (71/89) compared to 51.7% (46/89) with chest/sinus CT alone. Specificities were 32.14% (9/28) vs. 42.85% (12/28), respectively. PET/CT resulted in a change from the pre-test diagnosis in 63/91 (69%) of episodes and in modification of patients' management in 46/91 (55%). PET/CT was beneficial in diagnosing abdominal infections. PET/CT has a potential role in the diagnostic evaluation of patients with persistent febrile neutropenia.

The in-hospital mortality of patients with severe sepsis and septic shock (SSSS) is high. In this study we examined the diagnostic and prognostic accuracy of the emergency severity index (ESI), the modified early warning score (MEWS), and the mortality in emergency department (ED) sepsis (MEDS) score. This is a single-centre, prospective and observational study of 151 consecutive patients presenting to the ED of the Nuremberg Hospital with suspected sepsis (age 68.3 ± 18 years, 54.3 % men, 45 % with SSSS, in-hospital mortality of SSSS: 27.8 %). In this study, 37.7 % of the studied patients had a urinary tract infection (n = 57/151), 33.8 % a pneumonia (n = 51/151), 8.6 % an acute abdominal infection (n = 13/151), and in 12.6 % the focus of infection was not further specified or identifiable (n = 19/151). The diagnostic and prognostic accuracy was analyzed by means of the receiver operating characteristic (ROC) curve. The areas under curve (AUC) in terms of diagnostic accuracy were 0.609, 0.641, and 0.778 for the ESI, MEWS, and MEDS score respectively. The AUCs concerning prognostic accuracy were 0.617, 0.642, and 0.871 for ESI, MEWS, and MEDS score respectively. By using the MEDS score systematically, critically ill patients with sepsis could be detected in the ED. Finally, the MEDS score provides the basis for a risk adjusted disposition management that follows objective criteria.

Aim-Background: To estimate the impact of initial empiric antibiotic treatment failure on pharmacological and total healthcare costs in hospitalized patients with complicated intra–abdominal infections (cIAIs) in Greece. Methods: Adult patients with cIAIs hospitalized in 18 Greek surgical clinics over a 2-year period were included in this prospective observational study. Treatment failure was defined as the antibiotic addition or change (apart from intravenous to oral switch or de-escalation), the need for additional surgical procedure, or death. An average daily hospitalization cost was estimated based on the diagnosis at discharge and disease-related group mapping. Daily cost was then extrapolated for the incremental length of stay (LOS) associated with initial antibiotic failure. Costs included expenditure for additional intensive care unit (ICU) hospitalization and surgical interventions, and calculations followed a third party payer perspective (€2012). Results: A total of 201 patients with cIAIs met the inclusion criteria. Failure of the initial empiric antibiotic treatment was reported in 42.9% of subjects. The LOS was 21.9±16.4 and 8.9±4.5 days for “failed” versus “successful” patients, respectively. Total incremental per patient cost was estimated to be €3,761.56 inclusive of unsuccessful mean empiric antibiotic expenditure, the latter estimated at €220.06 per patient. Failure was related with previous antibiotic use, disease severity, antimicrobial resistance and co-morbidities, which in turn led to prolonged hospitalization, additional surgical procedures and hospitalization in the ICU. Conclusion: Subjects exhibiting failure of initial antibiotic treatment for cIAIs had a greater likelihood of requiring prolongation of hospitalization, increased use of healthcare resources and higher costs in an environment where resources are scarce.

Pylephlebitis is defined as an inflamed thrombosis of the portal vein. It is a rare complication of an intraabdominal infection, and the diagnosis is often missed due to its nonspecific clinical presentation. Symptoms may include abdominal pain, fever, chills, fatigue, nausea, and vomiting. It is important to consider this differential when a patient presents with signs of abdominal sepsis since it has a high mortality rate and is often diagnosed postmortem. Pylephlebitis can be diagnosed via abdominal ultrasound or CT demonstrating a thrombus in the portal vein, and it must be treated early and aggressively with broad-spectrum antibiotics. We are presenting a case of pylephlebitis as well as discussing the diagnosis and treatment of this potentially lethal condition. Keywords: pylephlebitis; portal vein thrombosis; abdominal infection; sepsis; diverticulitis; appendicitis; bacteroides (Published: 5 July 2013) Citation: Journal of Community Hospital Internal Medicine Perspectives 2013, 3 : 20732 - http://dx.doi.org/10.3402/jchimp.v3i2.20732

Background Clostridium difficile causes diarrhea that ranges from a benign, self-limiting antibiotic use-associated disease to a life-threatening pseudomembranous colitis. Clostridium difficile has rarely been isolated in extraintestinal infections. Our objective was to characterize clinical features and risk factors of these infections. METHODS Extraintestinal C. difficile infections (CDIs) were searched for in an electronic database of all C. difficile-positive isolates found during a 10-year period. The medical records were reviewed retrospectively. Disease severity and comorbidities of the patients were evaluated using Horn disease severity and Charlson comorbidity indexes. Results Extraintestinal CDI was found in 31 patients who comprised 0.17% of all CDIs. Two patients had bacteremic infections, 4 had abdominal infections without any prior surgery, 7 had abdominal infections after surgery, 4 had perianal abscesses, 13 had wound infections, and 1 had C. difficile in a urinary catheter. In most cases (85%), C. difficile was isolated together with other microbes. Most (81%) patients developed the infection when hospitalized and many had severe comorbidities. Sixteen (52%) had diarrhea. The 1-year mortality rate was 36% and it correlated with the severity of underlying diseases. Conclusions Extraintestinal CDIs occur mainly in hospitalized patients with significant comorbidities. Extraintestinal CDIs in the abdominal area may result from either intestinal perforation after infection or after intestinal surgery. Wound infections may result from colonization by feces. Clostridium difficile may reach distant sites via bacteremia. Mortality in extraintestinal CDIs is associated with the severity of underlying diseases.

Summary Objective: Tigecycline, a new glycylcycline antimicrobial agent, is indicated for the treatment of complicated skin structure infection (cSSTI), intra-abdominal infection (cIAI) and community acquired pneumonia. We aimed to evaluate the clinical and microbiological data together about tigecycline therapy. Methods: Patients with cIAIs and cSSTIs were included in a prospective, observational follow-up. Patient follow-up forms were developed and clinical and microbiological data were recorded. Results: Of the 107 patients, 67 had cSSTIs, 40 had cIAIs. Tigecycline was used empirically in 37.5% of cIAIs and in 50.7% of cSSTIs. In 85.0% of the patients with cIAI and in 73.1% of the patients with cSSTI, clinical and/or microbiological response could be achieved. A drug change was made in 26.9% and 7.5% of the patients with cSSTI and cIAI respectively. Superinfection was detected in 14.9% of the cSSTI and 7.5% of the cIAI patients. Conclusion: As a result, tigecycline can be safely used in the treatment of different infections. Compared with cSSTIs, the treatment response is better and the duration of treatment is shorter in cIAIs. However, MIC value must be determined at any rate if tigecycline is to be used in the treatment of Acinetobacter (MDR Acinetobacter, in particular) infections. Clinical cure and microbiological eradication rate of tigecycline therapy changes according to different clinical diagnosis and microorganism.

BACKGROUND To evaluate antimicrobial properties of Dermacyn in abdominal infections, and to develop a new method for peritoneal lavage without using antibiotics. METHODS One hundred and ten patients suffering from intestinal perforation (abdominal closed injury), who had been treated with opened surgical repair or partial intestinal resection, were enrolled in this study. In the study group, Dermacyn was used for peritoneal lavage. During the same period, 102 patients with intestinal perforation of abdominal closed injury and opened repair or partial intestinal resection were enrolled as a control group. For the control group, metronidazole physiological saline was used for peritoneal lavage. Patients from both groups had a postoperative indwelling peritoneal drainage tube. Five objective indicators were studied and compared at 24, 48, and 72 hours: volume of drainage, drainage fluid culture, blood routine test, C-reactive protein, calcitonin and antibiotics dose. RESULTS There were no significant differences between the drainage volumes in two groups three days after the operation. There were significant differences in the nature of the drainage fluid, bacterial culture results, blood routine, C-reactive protein and procalcitonin between the two groups. In the experimental group, after the Dermacyn flushing, the average volume of peritoneal drainage fluid was reduced (from 30 to 5 mL) from 24 to 72 hours postoperatively. CONCLUSIONS The use of Dermacyn as an antibiotic agent for intraoperative peritoneal lavage was effective in reducing the risk of infection, due to its broad-spectrum bactericidal effect. Dermacyn could be used safely to perform peritoneal flushing to clean the operation site.

BackgroundCurrent guidance on the management of sepsis often applies to infection originating from abdominal or pelvic sources, which presents specific challenges and opportunities for efficient and rapid source control. Advances made in the past decade are presented in this article.MethodsA qualitative systematic review was undertaken by searching standard literature databases for English-language studies presenting original data on the clinical management of abdominal and pelvic complex infection in adults over the past 10 years. High-quality studies relevant to five topical themes that emerged during review were included.ResultsImportant developments and promising preliminary work are presented, relating to: imaging and other diagnostic modalities; antimicrobial therapy and the importance of antimicrobial stewardship; the particular challenges posed by fungal sepsis; novel techniques in percutaneous and endoscopic source control; and current issues relating to surgical source control and managing the abdominal wound. Logistical challenges relating to rapid access to cross-sectional imaging, interventional radiology and operating theatres need to be addressed so that international benchmarks can be met.ConclusionImportant advances have been made in the diagnosis, non-operative and surgical control of abdominal or pelvic sources, which may improve outcomes in the future. Important areas for continued research include the diagnosis and therapy of fungal infection and the challenges of managing the open abdomen.

tudy Objective It is unknown if β-lactam monotherapy is sufficient for complicated intra-abdominal infections or if broader coverage is required, such as with vancomycin. This study sought to determine the clinical outcomes of piperacillin/tazobactam (PIP/TAZ) monotherapy compared to combination therapy with vancomycin and PIP/TAZ for complicated intra-abdominal infections among patients within a surgical intensive care unit (ICU). Design Retrospective cohort study. Setting Three surgical ICUs at a tertiary academic medical center. Patients Four hundred seventeen patients with a secondary peritonitis identified by International Classification of Diseases, Ninth Revision codes who received either PIP/TAZ monotherapy (228 patients) or PIP/TAZ and vancomycin combination therapy (189 patients). Measurements and Main Results The primary outcome was day 28 clinical cure; secondary outcomes included day 7 clinical cure, length of stay (LOS), and mortality. There were no statistically significant differences between the monotherapy and combination therapy groups with respect to day 28 clinical cure (33.9% vs 25.5%, p=0.064), day 7 clinical cure (23.6% vs 17.6%, p=0.14), or 28-day mortality (7% vs 7.9%, p=0.72). LOS in the ICU was significantly shorter in the monotherapy group (6 days) compared with the combination therapy group (7 days; p=0.04); however, hospital LOS was not significantly different. Conclusions No difference was observed in clinical cure rates at day 28 or day 7 between those who received PIP/TAZ monotherapy compared to PIP/TAZ and vancomycin combination therapy.

Background Epithelial dysplasia and adenomatous polyps of colorectum are precancerous lesions. Surgical removal is still one of the important treatment approaches for colorectal polyps. Case presentation A male patient over 78 years was admitted due to bloody stool and abdominal pain. Colonoscopic biopsy showed a high-grade epithelial dysplasia in an adenomatous polyp of sigmoid colon. Anemia, COPD, ischemic heart disease (IHD), arrhythmias, and hypoproteinemia were comorbidities. The preoperative preparation was carefully made consisting of oral nutritional supplements (ONS), blood transfusion, cardiorespiratory management, and hemostatic therapy. However, his illness did not improve but deteriorate mainly due to polyp rebleeding during preparative period. The open polypectomy was performed within 60 min under epidural anesthesia. Postoperative treatments included oxygen inhalation, bronchodilation, parenteral and enteral nutrition, human serum albumin, antibiotics, and blood transfusion. Unluckily, these did not significantly facilitate to surgical recovery on account of severe comorbidities and complications. The most serious complications were colonic leakage and secondary abdominal severe infection. The patient finally gave up treatment due to multiple organ dysfunction syndromes. Conclusions The polypectomy for colonic polyp is a seemingly minor but potentially deadly surgery for patients with severe comorbidities, and prophylactic ostomy should be considered for the safety.

Fever was frequently caused by opportunistic conditions in HIV-patients in the early years of the epidemic. Little is known about diagnostic spectrum and outcome of febrile episodes in patients with good access to antiretroviral therapy.We prospectively studied clinical presentation, diagnosis and outcome of febrile episodes in a contemporary cohort of HIV-patients with good access to antiretroviral therapy. Fever was defined as temperature 38.3 °C or higher, measured by a health care provider.We found 220 febrile episodes in 146 patients. In 25.9% of episodes the patient had a CD4 less than 200/mm³ and in 78.6% the patient was on antiretroviral therapy. There were multiple episodes in 44 patients. A diagnosis was established in 91.8%. Infection accounted for 82.3%, mainly respiratory tract infections, viral syndromes and abdominal infections. Malignancy, drug reactions and inflammatory conditions accounted together for less than 12% of episodes. Fifteen percent were attributed to opportunistic conditions. Episodes in patients with CD4 less than 200 were less likely to be caused by infection, but more likely to be caused by malignancy, drug reactions and opportunistic conditions. In 6.4% the patient died within six months after the onset of fever. Risk factors for death at six months in multivariable analysis were higher age and lower CD4.HIV-patients with access to antiretroviral therapy present with fever mostly due to conditions common in the general population. HIV-patients with low CD4 remain at risk for fever due to opportunistic conditions and death.

Background: In 2010, the EUPHAS 2 collaborative group created a registry with the purpose of recording data from critically ill patients suffering from severe sepsis and septic shock treated with polymyxin-B hemoperfusion (PMX-HP) for endotoxin removal. The aim of the registry was to verify the application of PMX-HP in the daily clinical practice. Methods: The EUPHAS 2 registry involved 57 centers between January 2010 and December 2014, collecting retrospective data of 357 patients (297 in Europe and 60 in Asia) suffering from severe sepsis and septic shock caused by proved or suspected infection related to Gram negative bacteria. All patients received atleast one cycle of extracorporeal endotoxin removal by PMX-HP. Results: Septic shock was diagnosed in 305 (85.4%) patients. The most common source of infection was abdominal (44.0%) followed by pulmonary (17.6%). Gram negative bacteria represented 60.6% of the pathogens responsible of infection. After 72h from the first cycle of PMX-HP, some of the SOFA score components significantly improved with respect to baseline: cardiovascular (2.16±1.77 from 3.32±1.29, p&nbsp

To describe a case of complete remission of thrombotic microangiopathy after treatment with eculizumab in a patient with non-Shiga toxin-associated bacterial enteritis. Case report: Medical/surgical intensive care unit (ICU) of a university teaching hospital. A 62-year-old man presented to a local hospital with mucous and bloody stool persisting for 1 month and worsening abdominal pain for 2 weeks. He had thrombocytopenia and renal dysfunction and was admitted with a diagnosis of sepsis due to intraabdominal infection. However, he did not respond to antimicrobial therapy, and after 7 days he was transferred to the Chiba University Hospital ICU. Antimicrobial therapy was continued, and continuous hemodiafiltration was initiated on ICU day 3, but the patient's condition deteriorated and he became anuric. Plasma exchange (PE) was initiated on ICU day 11, but anuria and thrombocytopenia persisted. Intravenous eculizumab therapy was initiated on day 26 and resulted in quick recovery of urine output and platelet count and successful discontinuation of renal support. The diagnosis of thrombotic microangiopathy was established by the presence of schistocytes on the peripheral blood smear on ICU day 9. A plasma sample collected prior to initiation of PE showed a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs member 13 (ADAMTS13) activity level of >10% (25.1%). The absence of both Shiga-toxin producing E coli in feces and anti-Shiga-toxin antibody in blood led to suspicion of atypical hemolytic uremic syndrome (aHUS). Genetic test identified a nonsynonymous mutation (p.Ala311Val) in the membrane cofactor protein gene (MCP). Although the pathological significance is currently unknown, this mutation may have been the cause of adult-onset aHUS in our patient. In this case, eculizumab was successfully introduced and discontinued, and the patient remained relapse-free after 1 year of follow-up. The duration of eculizumab therapy for patients with aHUS should be determined on a case-by-case basis and possibly according to the causative genetic mutation, even though discontinuation of eculizumab therapy once initiated is not generally recommended.

We investigated the efficacy and safety of a tissue expander (TE) for adjuvant radiotherapy (RT) of resected retroperitoneal sarcoma (RPS). This study was conducted with 37 patients with RPS who received resection with or without TE insertion followed by RT from August 2006 to June 2012 at Samsung Medical Center. Among the 37 patients, TE was inserted in 19. The quality of TE insertion was evaluated according to the correlation of clinical target volume and retroperitoneal surface volume covered by TE and was defined as follows: excellent, ≥85%; good, 70% to 85%; fair, 50% to 70%; and poor

Antimicrobial resistance is a global, emergent problem because an increasing numbers of serious community acquired and nosocomial infections are caused by resistant bacterial pathogens. It is a direct consequence of the excessive and irrational use of antibiotics. The use of antimicrobial agents is very high, often improper, in the department of general and emergency surgery and in the Intensive Cure Units to decrease morbidity and mortality rate related to intra-abdominal infections. Source control and empiric antibiotic therapy have to be administrated as early as possible to decrease high mortality rates in patients with severe sepsis or septic shock and, in this, the general surgeon has a crucial role. Proper antimicrobial stewardship in selecting an appropriate antibiotic and optimizing its dose and duration to cure intra-abdominal infections may prevent the emergence of AR and decrease costs for antibiotics.

Introducción: La infección intra-abdominal complicada adquirida en la comunidad (IIAc-AC) es una causa frecuente de abdomen agudo. Objetivo: Identificar el perfil clínico y microbiológico de la IIAc-AC en cuatro hospitales de Colombia. Métodos: Estudio descriptivo, prospectivo entre 07-2012 y 09-2014 en pacientes de 15 o más años con IIAc-AC. Se midieron las frecuencias de variables socio-demográficas, clínicas, diagnóstico, aislamientos y susceptibilidad antimicrobiana del primer cultivo obtenido asépticamente del sitio de infección. Resultados: 192 pacientes incluidos, 62% hombres, edad media 47,3 años; 38,4% con co-morbilidad, 13% hospitalizados en el último año y 9,4% recibieron antimicrobianos en los últimos seis meses. Fueron admitidos 44,3%, por apendicitis 17,7% por peritonitis y 16,7% por perforación intestinal. El 64,1% de las IIAc-AC fue moderada y tratada con ampicilina/sulbactam (SAM) y ertapenem. En 70,8% se aisló al menos un microorganismo en: 65,1% bacilos gramnegativos (80,0% Escherichia coli, 44,8% susceptible a piperacilina/tazobactam, 65,7% a SAM y 11,2% Klebsiella pneumoniae, 85% susceptibles a SAM) y en 16,7% especies grampositivas (28,1% Streptococcus grupo viridans). La mediana de hospitalización fue siete días y 15,1% fallecieron. Conclusión: Escherichia coli y K. pneumoniae en IIAc-AC son los principales microorganismos a cubrir en la terapia empírica y es necesario conocer la susceptibilidad antimicrobiana en cada región para seleccionar un tratamiento empírico adecuado. Introduction: Complicated community-acquired intra-abdominal infections (CA-cIAI) are a common cause of acute abdomen. Objective: To identify the clinical and microbiology profile of CA-cIAI in four Colombian hospitals. Methods: This is a prospective, descriptive study, between 08-2012 and 09-2014, including patients with CA-cIAI > 15 years. Data collected included: socio-demographic, clinical, diagnosis, and isolates of the first culture obtained aseptically during surgery with antimicrobial susceptibility. Results: 192 patients were included, 62% men, median age 47.3 years. Co-morbidities were present in 38.4%, 13% had been hospitalized in the previous year 13%, and 9.4% had received antibiotics in the last 6 months; 44.3% were admitted for appendicitis, 17.7% for peritonitis and 16.7% for bowel perforation. CA-cIAI were assessed as moderate in 64.1% of the cases and were treated with ampicillin/sulbactam (SAM) and ertapenem. In 70.8% of cases a bacteria was isolated: 65.1% were gramnegative rods (80.0% Escherichia coli, 44.8% of them susceptible to pipercillin/tazobactam, 65.7% to SAM; 11.2 % were K.pneumoniae, 85% was susceptible for SAM; 16.7% were grampositive cocci (28.1% Streptococci viridans group). The median hospital stay was 7 days and 15.1% died. Conclusions: E. coli, K. pneumoniae and S. viridans were the main organisms to consider in an empiric therapy for CA-cIAI and it is important to know the local epidemiology in order to choose the right antibiotic.

Background: Staphylococcal species are the most common organisms causing prosthetic mesh infections, however, infections due to rapidly growing mycobacteria are increasing. This study evaluates the resistance of biomaterial for abdominal wall prostheses against the development of postoperative infection in a rat model. Material and methods: In 75 rats, we intramuscularly implanted three different types of prostheses: (1) low-density polypropylene monofilament mesh (PMM), (2) high-density PMM, and (3) a composite prosthesis composed of low-density PMM and a nonporous hydrophilic film. Meshes were inoculated with a suspension containing 108 colony-forming units of Staphylococcus aureus, Staphylococcus epidermidis, Mycobacterium fortuitum, or Mycobacterium abscessus before wound closure. Animals were sacrificed on the eighth day postoperatively for clinical evaluation, and the implants were removed for bacteriologic analyses. Results: Prostheses infected with S aureus showed a higher bacterial viability, worse integration, and clinical outcome compared with infection by other bacteria. Composite prostheses showed a higher number of viable colonies of both M fortuitum and Staphylococcus spp., with poorer integration in host tissue. However, when the composite prosthesis was infected with M abscessus, a lower number of viable bacteria were isolated and a better integration was observed compared with infection by other bacteria. Conclusions: Considering M abscessus, a smaller collagen-free contact surface shows better resistance to infection, however, depending on the type of bacteria, prostheses with a large surface, and covered with collagen shows reduced resistance to infection, worse integration, and worse clinical outcome. (C) 2016 Elsevier Inc. All rights reserved.

Overall IDSA/SIS intra-abdominal infection guideline compliance was not associated with improved outcomes; however, there was a longer time to active therapy (P=.024) and higher mortality (P=.077) if empiric therapy was too narrow per guidelines. These findings support the need for the implementation of customized institutional guidelines adapted from the IDSA/SIS guidelines.Infect Control Hosp Epidemiol2016;37:855–858

Background The length of antimicrobial therapy in complicated intra-abdominal infections (CIAIs) is controversial. A recent prospective, multicenter, randomized controlled trial found that 4 days of antimicrobial therapy after source control of CIAI resulted in similar outcomes when compared with longer duration. We sought to examine whether outcomes remain similar in the subpopulation who received percutaneous drainage for source control of CIAI. Methods With the use of the STOP-IT database, patients with a CIAI who received percutaneous drainage were analyzed. Patients were randomized to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 days of therapy or to receive a fixed course of antibiotics for 4 ± 1 days. Outcomes included incidence of and time to recurrent intra-abdominal infection, Clostridium difficile infection, and extra-abdominal infections as well as hospital days and mortality. Results Of 518 enrolled patients, 129 met inclusion criteria. Baseline characteristics, including demographics, comorbidities, and severity of illness, were similar. When comparing outcomes of the 4-day group (n = 72) with those of the longer group (n = 57), rates of recurrent intra-abdominal infection (9.7% vs. 10.5%, p = 1.00), C. difficile infection (0% vs. 1.8%, p = 0.442), and hospital days (4.0 [2.0-7.5] vs. 4.0 [3.0-8.0], p = 0.91) were similar. Time to recurrent infection was shorter in the 4-day group (12.7 [6.2] days vs. 21.3 [4.2] days, p = 0.015). There was no mortality. Conclusion In this post hoc analysis of a prospective, multicenter, randomized trial, there was no difference in outcome between a shorter and longer duration of antimicrobial therapy in those with percutaneously drained source control of CIAI. Level of evidence Therapeutic/care management study, level IV.

Comamonas testosteroni (C. testosteroni) has been rarely observed as an infectious agent in clinical practice. Few reports described its potential pathogenicity in bloodstream and abdominal infections. Here, we report our experience in the treatment of a C. testosteroni-associated peritonitis in a four-year-old girl receiving chronic peritoneal dialysis (PD). The organism was shown to be highly susceptible to appropriate antibiotic therapy. Infection responded promptly and the patient was managed conservatively without withdrawal from PD.

BACKGROUND: In many cases of suspected sepsis, causative microorganisms cannot be isolated. Multiplex real-time PCR generates results more rapidly than conventional blood culture systems. METHODS: In this study, we evaluated the diagnostic performance of multiplex real-time PCR (LightCycler (R) SeptiFast, Roche, Mannheim, Germany), and compared with blood cultures and cultures from focus of infection in nosocomial sepsis. RESULTS: Seventy-eight nosocomial sepsis episodes in 67 adult patients were included in this study. The rates of microorganism detection by blood culture and PCR were 34.2% and 47.9%, respectively. Sixty-five microorganisms were detected by both methods from 78 sepsis episodes. Nineteen of these microorganisms were detected by both blood culture and PCR analysis from the same sepsis episode. There was statistically moderate concordance between the two methods (kappa=0.445, P

Background: Surgical site infections (SSI) are seen in up to 5% of patients after appendectomy for acute appendicitis. SSI are associated with prolonged hospital stay and increased costs. The aim of this multicenter study was to identify factors associated with SSI after appendectomy for acute appendicitis. Methods: Patients who underwent appendectomy for acute appendicitis between June 2014 and January 2015 in 6 teaching hospitals in the southwest of the Netherlands were included. Patient, diagnostic, intra-operative and disease-related factors were collected from the patients' charts. Primary outcome was surgical site infection. Multivariable logistic regression was performed to identify independent risk factors for SSI. Results: Some 637 patients were included. Forty-two patients developed a SSI. In univariable analysis body temperature >38°C, CRP>65 and complex appendicitis were associated with SSI. After multivariable logistic regression with stepwise backwards elimination, complex appendicitis was significantly associated with SSI (OR 4.09; 95% CI 2.04-8.20). Appendiceal stump closure with a stapler device was inversely correlated with SSI (OR 0.40; 95% CI 0.24-0.97) Conclusions: Complex appendicitis is a risk factor for SSI and warrants close monitoring postoperatively. The use of a stapler device for appendiceal stump closure is associated with a reduced risk of SSI.

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

To compare the early efficacy of external versus internal pancreatic duct drainage after pancreaticoduodenectomy (PD), providing clinical evidence for selecting the optimal approach to pancreatic duct drainage.The clinical data of 395 consecutive patients undergoing PD from 2006 to 2013 were analyzed retrospectively. All the patients were divided into external and internal drainage group. Intraoperative blood loss, surgery duration, postoperative hospitalization duration, mortality rate, PF, and other complications were compared between the two groups. The perioperative relative risk factors that might induce PF were analyzed.External drainage significantly reduced the incidences of post-PD PF, delayed gastric emptying, abdominal infection, bowel obstruction, overall complications, and shortened the healing time of PF (p.05). The univariate analysis showed that the pancreatic duct drainage method, body mass index (BMI), preoperative serum bilirubin level, perioperative blood transfusion, pancreaticojejunostomy approach, pancreatic texture, pancreatic duct diameter, and primary disease differed markedly between the two groups (p.05). A multivariate analysis revealed that BMI ≥ 25 kg/m(2), internal pancreatic duct drainage, pancreatic duct diameter3 mm, soft pancreatic texture, and ampullary disease were independent risk factors for PF.External pancreatic duct drainage can effectively reduce the morbidity of PF and overall complications after PD.

The number of organ donors is limited by many contraindications for donation and poor quality of potential organ donors. Abdominal infection is a generally accepted contraindication for donation of abdominal organs. We present a 43-year-old man with lethal brain injury, blunt abdominal trauma, and intestinal perforation. After withdrawal of life-sustaining treatment and circulatory arrest, a minilaparotomy confirmed abdominal contamination with intestinal content. After closure of the abdomen, organs were preserved with in situ preservation with an aortic cannula inserted via the femoral artery. Thereafter, the kidneys were procured via bilateral lumbotomy to reduce the risk of direct bacterial contamination; lungs were retrieved following a standard practice. There was no bacterial or fungal growth in the machine preservation fluid of both kidneys. All organs were successfully transplanted, without postoperative infection, and functioned well after 6 months. We hereby show that direct contamination of organs can be avoided with the use of in situ preservation and retroperitoneal procurement. Intestinal perforation is not an absolute contraindication for donation, although the risk of bacterial or fungal transmission has to be evaluated per case.

Background.Long-term outcomes (mortality and health-related quality of life) of sepsis have risen as important indicators for health care. Pulmonary infection and abdominal infection are the leading causes of sepsis. However, few researches about long-term outcomes focused on the origin of sepsis. Here we aim to study the clinical differences between pulmonary-sepsis and abdominal-sepsis and to investigate whether different infection foci were associated with long-term outcomes.Methods.Patients who survived after hospital discharge were followed up by telephone interview. Quality of life (QoL) was assessed using the EuroQol 5-dimension (EQ5D) questionnaire.Results.Four hundred and eighty-three sepsis patients were included, 272 (56.3%) had pulmonary-sepsis, and 180 (37.3%) had abdominal-sepsis. The overall ICU and one-year mortality rates of the cohort were 17.8% and 36.1%, respectively. Compared with abdominal-sepsis, pulmonary-sepsis patients had older age, higher APACHE II, higher ICU mortality (31.7% versus 12.6%), and one-year mortality (45.4% versus 24.4%), together with worse QoL. Age, septic shock, acute renal failure, fungus infection, anion gap, and pulmonary infection were predictors for one-year mortality and pulmonary infection was a risk factor for poor QoL.Conclusions.Pulmonary-sepsis showed worse outcome than abdominal-sepsis. Pulmonary infection is a risk factor for one-year mortality and QoL after sepsis.

Background Pylephlebitis, a rare complication of abdominal infections, is a septic thrombophlebitis of the portal venous system with high rates of morbidity and mortality. Case Report We present a case of pylephlebitis complicating acute appendicitis and report the utility of a computed tomography scan in the diagnosis. Why Should an Emergency Physician be Aware of This? The prompt diagnosis and appropriate treatment of pylephlebitis are crucial to reduce morbidity and mortality, but clinical presentation is often nonspecific. A computed tomography scan is instrumental in the early diagnosis of pylephlebitis because it readily reveals the thrombus in the mesenteric or portal vein in the setting of acute appendicitis. Early and aggressive treatment with broad-spectrum antibiotics is necessary, and anticoagulation therapy can also be used to prevent bowel ischemia. © 2016 Elsevier Inc.

Pancreas transplantation offers the most reliable way to achieve euglycemia for insulin-dependent patients. Thanks to refinements in surgical technique, immunosuppression, donor and recipient selection, improved outcomes have been achieved. Unfortunately, the incidence of complications after pancreas transplant remains the highest of all performed solid organ transplants. In the last decade, the numbers of procedures performed and new listings have suffered a steady decline. Technical failure is the most common cause of pancreas graft loss in the first-year posttransplant, most notably manifesting as vascular thrombosis in half of the cases, followed by infections. The spectrum of possible infections is wide, and no completely satisfactory classification system exists. Some are related directly to the surgical procedure or to complications that develop afterwards. Classification by pathogen into bacterial, viral, or fungal infections is not always clinically useful. One pathogen may be involved in several different infections, or a number of different pathogens may be involved in a single infection. Classification by timing posttransplant, into early, intermediate, or late infections, has some merit as many infections follow a typical temporal pattern. Classification based on surgical and medical infections is useful in a broad sense as it will delineate future interventions.

Background: Pyogenic liver abscess (PLA) after surgery may lead to sepsis.Endoscopic techniques provide an alternative choice for PLA drainage. Methods: We describe a 49-year-old woman who developed a right PLA after left lobe hepatectomy and common bile duct (CBD) exploration due to intra-and extra-hepatic bile duct stones. Results: The patient suffered from persistent high fever and hyperbilirubinemia with unknown reason after surgery despite amount of antibiotic applied until a liver abscess in right lobe was found .It was treated with ultrasound-guided percutaneous transhepatic drainage(PTD). However, outcome of the PTD was worse because of no fluid collected in abscess cavity at that time. T-tube drainage suddenly stop work after post-operative day 4. Emergent Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Nasobiliary Drainage (ENBD) was performed. The patient recovered rapidly a week later. Conclusions: PLA induced by regional closed-loop biliary obstruction is an important reason of abdominal infection after surgery.Endoscopic techniques with ERCP and ENBD can resolve PLA in early stage especially when PTD inadequently drained.

Background Intra-abdominal infections (IAI) constitute a common reason for hospitalization. However, there is lack of standardization in empiric management of (1) anaerobes, (2) enterococci, (3) fungi, and (4) multidrug-resistant organisms (MDRO). The recommendation is to institute empiric coverage for some of these organisms in “high-risk community-acquired” or in “healthcare-associated” infections (HCAI), but exact definitions are not provided. Methods Epidemiological study of IAI was conducted at Assaf Harofeh Medical Center (May–November 2013). Logistic and Cox regressions were used to analyze predictors and outcomes of IAI, respectively. The performances of established HCAI definitions to predict MDRO-IAI upon admission were calculated by receiver operating characteristic (ROC) curve analyses. Results After reviewing 8219 discharge notes, 253 consecutive patients were enrolled (43 [17%] children). There were 116 patients with appendicitis, 93 biliary infections, and 17 with diverticulitis. Cultures were obtained from 88 patients (35%), and 44 of them (50%) yielded a microbiologically confirmed IAI: 9% fungal, 11% enterococcal, 25% anaerobic, and 34% MDRO. Eighty percent of MDRO-IAIs were present upon admission, but the area under the ROC curve of predicting MDRO-IAI upon admission by the commonly used HCAI definitions were low (0.73 and 0.69). Independent predictors for MDRO-IAI were advanced age and active malignancy. Conclusions Multidrug-resistant organism-IAIs are common, and empiric broad-spectrum coverage is important among elderly patients with active malignancy, even if the infection onset was outside the hospital setting, regardless of current HCAI definitions. Outcomes analyses suggest that empiric regimens should routinely contain antianaerobes (except for biliary IAI); however, empiric antienterococcal or antifungals regimens are seldom needed.

other Rehberler, konu ile ilgili farklı uzmanlık alanlarından uzmanların her ülkenin kendi verilerini dikkate alarak hazırladıkları önerileri içerir. Ancak ülkemizde bugüne kadar intra-abdominal infeksiyonlar (İAİ) için ortak dil oluşturmak adına, önerileri kapsayan bir rehber kullanıma sunulmamıştır. Bunun en önemli nedeni klinikte İAİ'ların tanı ve tedavisi ile ilgili veya İAİ tanılı hastalardan elde edilen mikroorganizma duyarlılıklarını değerlendiren laboratuvar çalışmalarının oldukça az sayıda olmasıdır. Oysa günümüzde farklılaşan konak özellikleri ve gelişen teknolojik tedavi yöntemleri nedeniyle "ortak dil kullanmak" zorunluluk haline gelmiştir. Bu amaçla Mayıs 2015'te; Türkiye Enfeksiyon Hastalıkları ve Klinik Mikrobiyoloji Uzmanlık Derneği (EKMUD)'nin önderliğinde Türk Cerrahi Derneği, Türk Kolon ve Rektum Cerrahisi Derneği, Fıtık Derneği, Türk Hepatopankreatobilier Cerrahi Derneği, Türk Hastane İnfeksiyonları ve Kontrolü Derneği üyelerinden konuya ilgi duyan toplam 15 uzman tarafından yapılan toplantılarda çalışmalar değerlendirildi. Sonuçta, erişkinler için hazırlanan bu uzlaşı raporundaki öneriler, ağırlıklı olarak Amerika İnfeksiyon Hastalıkları [Infectious Diseases Society of America (IDSA)] ve Cerrahi İnfeksiyon Derneği (Surgical Infection Society) tarafından hazırlanan erişkin ve çocuklarda komplike İAİ'ların tanısı ve yönetimi 2010 rehberi olmak üzere, ulaşılabilen rehberlerden yararlanılarak ülkemiz verileriyle hazırlandı. Öneriler; hasta ile ilk karşılaşmadan başlayarak tanısal değerlendirme ve tedavi yaklaşımı olmak üzere iki bölümde oluşturuldu. Hazırlanan uzlaşı raporu ilk kez Antalya'da EKMUD 2016 kongresinde sunuldu. Takiben bir ay süre ile derneklerin sitelerinde önerilere açıldı. Öneriler alındıktan sonra gözden geçirilerek son hali makale olarak yazıldı Guidelines include the recommendations of experts from various specialties within a topic in consideration of data specific to each country. However, to date there has not been a guideline standardizing the nomenclature and offering recommendations for intra-abdominal infections (IAIs) in Turkey. This is mainly due to the paucity of laboratory studies regarding the clinical diagnosis and treatment of IAIs or the sensitivity of microorganisms isolated from patients with IAIs. However, due to the diversification of host characteristics and advancements in technological treatment methods, it has become imperative to 'speak a common language'. For this purpose May 2015, a group of 15 experts in intra-abdominal infections, under the leadership of the Infectious Diseases and Clinical Microbiology Specialty Society of Turkey (EKMUD) and with representatives from the Turkish Surgical Association, Turkish Society of Colon and Rectal Surgery, Hernia Society, Turkish Society of Hepato-pancreato-biliary Surgery, and the Turkish Society of Hospital Infections and Control, was formed to analyze relevant studies in the literature. Ultimately, the suggestions for adults found in this consensus report were developed using available data from Turkey, referring predominantly to the 2010 guidelines for diagnosing and managing complicated IAIs in adults and children by the Infectious Diseases Society of America (IDSA) and the Surgical Infection Society. The recommendations are presented in two sections, from the initial diagnostic evaluation of patients to the treatment approach for IAI. This Consensus Report was presented at the EKMUD 2016 Congress in Antalya and was subsequently opened for suggestions on the official websites of the Infectious Diseases and Clinical Microbiology Specialty Society of Turkey and Turkish Surgical Association for one month. The manuscript was revised according to the feedback received

Surgical intensive care unit (ICU) stay of greater than ten days is often described by the experienced intensivist as a ‘complicated clinical course’, and is frequently attributed to persistent immune dysfunction. ‘Systemic inflammatory response syndrome’ (SIRS) followed by ‘compensatory anti-inflammatory response syndrome’ (CARS) is a conceptual framework to explain the immunological trajectory that ICU patients with severe sepsis, trauma or emergency surgery for abdominal infection often traverse, but the causes, mechanisms and reasons for persistent immune dysfunction remain unexplained. Often involving multiple organ failure (MOF) and death, improvements in surgical intensive care have altered its incidence, phenotype and frequency, and have increased the number of patients who survive initial sepsis or surgical events and progress to a persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Often observed, but rarely reversible, these patients may survive to transfer to a long-term care facility only to return to the ICU, but rarely to self sufficiency. We propose that PICS is the dominant pathophysiology and phenotype that has replaced late MOF, and prolongs surgical ICU stay, usually with poor outcome. This review details the evolving epidemiology of MOF, the clinical presentation of PICS, and our understanding of how persistent inflammation and immunosuppression defines the pathobiology of prolonged intensive care. Therapy for PICS will require efficacy for multiple immune system defects and protein catabolism, and will involve innovative interventions for immune system rebalance and nutritional support to regain physical function and well being.

Enterotomy is a significant complication of laparoscopic ventral or incisional hernia repair (LVHR) and can be devastating if missed. Enterotomy occurs in 2.6% of patients undergoing LVHR and is missed 21.8% of the time. Controversy exists regarding the management of known or potential enterotomies. Approaches for managing recognized enterotomies during hernia repair are usually employed immediately; in a nonstaged fashion; and include laparoscopic enterotomy repair with immediate LVHR, laparotomy for repair of enterotomy with concomitant LVHR, or conversion to laparotomy for both enterotomy and hernia repair. The staged approach for managing recognized or potential enterotomies is less commonly employed and involves lapa- roscopic repair of enterotomy, admission, and delayed but definitive laparoscopic hernia repair in the same hospitaliza- tion. The presence of known or potential enterotomies during LVHR presents a difficult problem and may be a contraindication for immediate placement of prosthetic because of increased risks posed for abdominal infection, reopera- tion, prosthetic removal, hernia recurrence, and death. The staged approach—with a 2- to 5-day delay—represents a safe solution to this challenging problem. We present 4 cases managed via staged approach due to an enterotomy, risk factors, and suspicion for missed or delayed enteroto- mies augmented by a review of the literature.

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

Complicated intra-abdominal infections (cIAI) are a common problem in surgical practice. The effect of body mass index (BMI) on the outcome is poorly understood. We compared the association of BMI and type of antibiotic therapy for cIAI described in a previously published trial of ertapenem vs. piperacillin-tazobactam (Namias N, Solomkin JS, Jensen EH, et al. Randomized, multicenter, double-blind study of efficacy, safety, and tolerability of intravenous ertapenem versus piperacillin/tazobactam in treatment of complicated intra-abdominal infections in hospitalized adults. Surg Infect 2007;8:15-28).A post-hoc analysis was performed using data obtained from the published study. The effect of BMI and type of antibiotic used for therapy were calculated for clinically favorable outcomes at early follow-up assessment (EFA).The 231 patients who were microbiologically evaluable at EFA were stratified by BMI (30 or ≥30 kg/m(2)). Twelve patients were excluded because of missing BMI data, leaving 219 patients for analysis. There were some differences in baseline characteristics between patients with a BMI30 kg/m(2), including the source of intra-abdominal infection (more appendicitis in BMI30 group; p=0.01) and gender (more men in the BMI30 group; p=0.03). There was no difference in cure rates between the groups (82.9% for BMI30 kg/m(2) vs. 74.5% for those with BMI ≥30 kg/m(2); 8% difference in proportions, 95% confidence interval [CI] -5%, 25%). There was an 80% favorable clinical response to ertapenem in the BMI30 group compared with an 81% favorable rate in the BMI ≥30 group (-1% difference in proportions; 95% CI -22%, 19%). This compared with an 86% favorable response rate to piperacillin-tazobactam in the BMI30 group vs. a 65% favorable clinical response rate in the BMI ≥30 group (21% difference in proportions; 95% CI -1%, 47%).There was no difference in the cure rate of patients with cIAI in the BMI30 and BMI ≥30 kg/m(2) groups. There were no statistically significant differences in the likelihood of response to an antibiotic regimen. However, there was a nominally 21% lower cure rate in the high BMI group receiving piperacillin-tazobactam (86% vs. 65%; 21% difference in proportions; 95% CI -1%, 47%), whereas there was only a 1% difference in the cure rate between BMI groups in the patients receiving ertapenem. This difference may be related to gender and etiology of infection. Although limited by the small number of high BMI patients and post-hoc methodology, these results merit consideration of the design of future prospective antibiotic trials to include stratification for BMI and consideration of the effect of BMI on pharmacokinetics and pharmacodynamics.

To evaluate the efficacy and safety of moxifloxacin monotherapy for treatment of complicated intra-abdominal infections. PubMed, EMBASE, Science Direct, ClinicalTrials.gov and Cochrane Central Register of Controlled Trials were searched to retrieve randomised controlled trials (RCTs) compared moxifloxacin monotherapy with other antibiotics in the treatment of complicated intra-abdominal infections from January 1999 to July 2011. A meta-analysis of all included randomised controlled trials was performed. Four randomised controlled trials including a total of 2444 patients with complicated intra-abdominal infections were included for meta-analysis. The results of the meta-analysis indicated that the moxifloxacin was associated with similar clinical cure rate (four RCTs, 1934 patients, OR = 0.80, 95% CI: 0.61, 1.04, p = 0.09), bacteriological success rates (four RCTs, 1484 patients, OR = 0.79, 95% CI: 0.59, 1.05, p = 0.11) and mortality (four RCTs, 2227 patients, OR = 0.91, 95% CI: 0.45, 1.83, p = 0.79) compared with the control group. The overall incidence of adverse events of moxifloxacin was significantly higher than that in the control group (three RCTs, 1367 patients, OR = 1.33, 95% CI: 1.07, 1.63, p = 0.008), although the incidence of drug-related adverse events (three RCTs, 1601 patients, OR = 1.13, 95% CI: 0.69, 1.85, p = 0.63) and serious adverse events (three RCTs, 1815 patients, OR = 1.23, 95% CI: 0.59, 2.60, p = 0.58) were similar between the compared treatment groups. Moxifloxacin is an effective and relatively safe option for the treatment of patients with intra-abdominal infections. Moxifloxacin monotherapy has similar efficacy to combination therapy.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are significantly associated with morbidity and mortality. We performed a prospective observational study and applied recently published consensus criteria to measure and describe the incidence of IAH and ACS, identify risk factors for their development and define their association with outcomes. We studied 100 consecutive patients admitted to our general intensive care unit. We recorded relevant demographic, clinical data and maximal (max) and mean intra-abdominal pressure (IAP). We measured and defined IAH and ACS using consensus guidelines. Of our study patients, 42% (by IAPmax) and 38% (by IAPmean) had IAH. Patients with IAH had greater mean body mass index (30.4±9.6 vs 25.4±5.6 kg/m2, P=0.005), Acute Physiology and Chronic Health Evaluation III score (78.2±28.5 vs 65.5±29.2, P=0.03) and central venous pressure (12.8±4.8 vs 9.2±3.5 mmHg, P