[Interpretation of domestic and foreign guidelines on diagnosis and treatment of abdominal infection].

In recent years, both international and domestic societies have published several guidelines on diagnosis and management of intra-abdominal infection. Due to the different evidence and the different methods adopted in the actual formulation of the guidelines, the recommendations of each version of the guidelines are different. Three international guidelines with great impacts were reviewed, including Diagnosis and management of complicated intra-abdominal infection: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America published in 2010, The Surgical Infection Society revised guidelines on the management of intra-abdominal infection published in 2017, and The management of intra-abdominal infections from a global perspective by the World Society of Emergent Surgery. The above guidelines were used to compare with the Chinese guidelines on the diagnosis and management of intra-abdominal infection (2019) which was published in early 2020. Recommendations on the disease severity classification, source control, and antimicrobial therapy are further explained in order to provide guidelines for clinicians.

Clinical spectrum of intra-abdominal abscesses in patients admitted to the emergency department.

BACKGROUND: The mortality of undrained abdominal abscesses may be as high as 35 %. In this study, we analyzed the clinical spectrum of intra-abdominal abscess (IAA) patients in the ED and attempted to identify factors that can predict the severity of IAA. METHOD: This study was a retrospective review of adults (≥ 18 years) with IAA admitted to a single ED. IAA were diagnosed by abdominal computed tomography. The differences in clinical variables between patients receiving and not receiving inotropic drugs were analyzed. Multiple logistic regression was performed for assessing predictor variables. RESULTS: 128 patients presented with IAA. The most common complaint was abdominal pain (60.2 %) and the liver was most common location (39.8 %). Patients who required inotropic drugs had lower serum leukocyte, lymphocyte, and platelet counts and higher serum BUN and CRP levels. The independent factors associated with need for inotropic drugs were serum leukocyte, CRP, and BUN level. The optimal cutoff CRP value for predicting inotropic drug use was 12.06mg/dL, BUN value was 21mg/dL. CONCLUSIONS: Elevated CRP and BUN levels could predict a higher association with requirement of inotrope. Therefore, emergency physicians should consider CRP and BUN levels and aiming for early aggressive treatment.

Temperature-Neutrophils-Multiple Organ Failure Grading for Complicated Intra-Abdominal Infections.

Background: The grading systems for intra-abdominal sepsis (IAS) are not employed commonly in clinical practice because they are too complicated or too specific. We propose to grade IAS with a simple grading system: the TNM system, which is an acronym borrowed from cancer staging, where T indicates Temperature, N indicates Neutrophils, and M indicates Multiple organ failure (MOF). The aim of this prospective observational study is to assess the predictive value of the TNM score on deaths of patients with complicated IAS. Patients and Methods: We considered 147 patients with complicated IAS. Three classes of attribute were chosen: Temperature (T), Neutrophil count (N), and MOF (M). After defining the categories T (T0-T4), N (N0-N3), and M (M0-M2), they were grouped in stages (0-IV). We analyzed specific variables for their possible relation to death: Age, gender, blood transfusion, causes of IAS, T, N, pre-operative organ failure, immunocompromised status, stage 0, I, II, III, and IV. Odds ratios were calculated in a uni-variable and multi-variable analysis. Results: This was the distribution in classes, based on TNM stages: One patient was in stage 0; 15 patients in stage I; 47 patients in stage II; 56 patients in stage III; 28 patients in stage IV. Death occurred in 45 (30.6%) patients. The N, pre-operative organ failure, immunocompromised status, stage III-IV were potential predictors of post-operative death in uni-variable analysis. Only pre-operative organ failure and stage IV were significant independent predictors of post-operative death in multi-variable analysis. Conclusions: The TNM classification is an easy system that could be considered to define the death risk of patients with IAS and to compare patients with sepsis.

[Pathogenesis and classification of advanced peritonitis]. / Patogenez i klassifikatsiia rasprostranennogo peritonita.

The concept of pathogenesis of peritonitis and abdominal sepsis are discussed in the article. Significant scientific findings devoted to this issue occurred in recent years. Nevertheless, there is still no unity in understanding the pathogenesis of peritonitis. Accordingly, the question of its classification is still open. Literature review demonstrates diverse opinions regarding classification of peritonitis. The authors analyze the arguments for and against some classification categories taken on the basis of pathophysiological aspects of this serious complication of abdominal diseases.

Intra-abdominal sepsis: new definitions and current clinical standards.

PURPOSE: The abdomen is the second most common source of sepsis and is associated with unacceptably high morbidity and mortality. Recently, the essential definitions of sepsis and septic shock were updated (Third International Consensus Definitions for Sepsis and Septic Shock, Sepsis-3) and modified. The purpose of this review is to provide an overview of the changes introduced by Sepsis-3 and the current state of the art regarding the treatment of abdominal sepsis. RESULTS: While Sepsis-1/2 focused on detecting systemic inflammation as a response to infection, Sepsis-3 defines sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. The Surviving Sepsis Campaign (SSC) guideline, which was updated in 2016, recommends rapid diagnosis and initiating standardized therapy. New diagnostic tools, the establishment of antibiotic stewardship programs, and a host of new-generation antibiotics are new landmark changes in the sepsis literature of the last few years. Although the "old" surgical source control consisting of debridement, removal of infected devices, drainage of purulent cavities, and decompression of the abdominal cavity is the gold standard of surgical care, the timing of gastrointestinal reconstruction and closure of the abdominal cavity ("damage control surgery") are discussed intensively in the literature. The SSC guidelines provide evidence-based sepsis therapy. Nevertheless, treating critically ill intensive care patients requires individualized, continuous daily re-evaluation and flexible therapeutic strategies, which can be best discussed in the interdisciplinary rounds of experienced surgeons and intensive care medicals.

Antimicrobial susceptibilities of specific syndromes created with organ-specific weighted incidence antibiograms (OSWIA) in patients with intra-abdominal infections.

BACKGROUND: The aim was to evaluate the value of organ-specific weighted incidence antibiogram (OSWIA) percentages for bacterial susceptibilities of Gram-negative bacteria (GNB) collected from intra-abdominal infections (IAIs) during SMART 2010-2014. METHODS: We retrospectively calculated the OSWIA percentages that would have been adequately covered by 12 common antimicrobials based on the bacterial compositions found in the appendix, peritoneum, colon, liver, gall bladder and pancreas. RESULTS: The ESBL positive rates were 65.7% for Escherichia coli, 36.2% for Klebsiella pneumoniae, 42.9% for Proteus mirabilis and 33.1% for Klebsiella oxytoca. Escherichia coli were mainly found in the appendix (76.8%), but less so in the liver (32.4%). Klebsiella pneumoniae constituted 45.2% of the total liver pathogenic bacteria and 15.2-20.8% were found in 4 other organs, except the colon and appendix (< 10%). The percentages of Pseudomonas aeruginosa infections were higher in the gall bladder, intra-abdominal abscesses, pancreas and colon (10.2-13.2%) and least (5.4%) in the appendix. The susceptibilities of hospital acquired (HA) and community acquired (CA) IAI isolates from appendix, gall bladder and liver showed ≥80% susceptibilities to amikacin (AMK), imipenem (IPM), piperacillin-tazobactam (TZP) and ertapenem (ETP), while the susceptibility of isolates in abscesses and peritoneal fluid showed ≥80% susceptibility only to amikacin (AMK) and imipenem (IPM). In colon CA IAI isolates susceptibilities did not reach 80% for AMK and ETP, and in pancreatic IAIs susceptibilities of HA GNBs did not reach 80% to AMK, TZP and ETP, and CA GNBs to IMP and ETP. In addition, besides circa 80% susceptibility of HA and CA IAI isolates from appendix to cefoxitin (FOX), IAI isolates from all other organs had susceptibilities between 7.6 and 67.9% to all cephalosporins tested, 28.3-75.2% to fluoroquinolones and 7.6-51.0% to ampicillin-sulbactam (SAM), whether they were obtained from CA or HA infections. CONCLUSION: The calculated OSWIA susceptibilities were specific for different organs in abdominal infections.

Prospective evaluation of the Sunshine Appendicitis Grading System score.

BACKGROUND: Although there is a wealth of information predicting risk of post-operative intra-abdominal collection and guiding antibiotic therapy following appendicectomy, confusion remains because of lack of consensus on the clinical severity and definition of 'complicated' appendicitis. This study aimed to develop a standardized intra-operative grading system: Sunshine Appendicitis Grading System (SAGS) for acute appendicitis that correlates independently with the risk of intra-abdominal collections. METHODS: Two-hundred and forty-six patients undergoing emergency laparoscopy for suspected appendicitis were prospectively scored according to the severity of appendicitis and followed up for complications including intra-abdominal collection. After termination of the study, the SAGS score was repeated by an independent surgeon based on operation notes and intra-operative photography to determine inter-rater agreement. The primary outcome measure was incidence of intra-abdominal collection, secondary outcome measures were all complications and length of stay. RESULTS: SAGS score demonstrated good inter-rater agreement (kappa Kw 0.869; 95% CI 0.796-0.941; P < 0.001). A risk ratio of 2.594 (95% CI 0.655-4.065; P < 0.001) for intra-abdominal collection was found using SAGS score as a predictor. The discriminative ability of SAGS score was supported by an area under the curve value of 0.850 (95% CI 0.799-0.892; P < 0.001). CONCLUSIONS: SAGS score can be used to simply and accurately classify the severity of appendicitis and to independently predict the risk of intra-abdominal collection. It can therefore be used to stratify risk, guide antibiotic therapy, follow-up and standardize the definitions of appendicitis severity for future research.