Microbiological profiles and clinical outcomes of critically ill surgical patients with lower gastrointestinal perforation in Japan: a single-center retrospective observational study.

BACKGROUND: Lower gastrointestinal perforation (LGP) is a surgical emergency disease that can result in secondary bacterial peritonitis. Microbiological studies on LGP are rare. The present study aimed to ascertain the microbiological profile of LGP in patients admitted to the intensive care unit (ICU) at our institute after surgery. In addition, we investigated whether initial empirical therapy with vancomycin was associated with in-hospital mortality, duration of ICU stay, and duration of ventilator support. METHODS: This single-center, retrospective, observational study was conducted at Kobe City Medical Center General Hospital, Japan. The study population included all patients diagnosed with LGP who were admitted to the ICU after emergency surgery between 2017 and 2023. The primary outcome assessed was the microbiological profile of microorganisms isolated from ascites fluid and blood of the participants. The secondary end-points were in-hospital mortality, duration of ICU stay, and duration of ventilator support. We performed univariate and multivariate regression analyses to evaluate the end-points. RESULTS: During the study period, 89 patients were included in the analysis. The most commonly identified pathogen from the ascites cultures was Escherichia coli (65.2%), followed by Enterococcus spp. (51.7%). E. faecium was identified in 16 (18.0%) ascites samples. The microbiological profile of critically ill patients with LGP admitted to the ICU after surgery was similar to that of previous studies on intra-abdominal infection (IAI). Therefore, the initial empirical therapy in the IAI guidelines is more appropriate for LGP. Multivariate regression analysis suggested that the combination of initial empirical therapy with vancomycin was not associated with in-hospital mortality (odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.23-3.00, p = 0.955), duration of ICU stay (coefficient=-0.92, 95% CI -3.04-1.21, p = 0.393), or duration of ventilator-support (coefficient=-9.03, 95%CI -49.69-31.63, p = 0.659). CONCLUSION: The microbiological profile of critically ill patients with LGP admitted to the ICU after surgery was similar to that of previous studies on IAI. However, the frequency of E. faecium in the present study was higher than that in previous studies. Initial empirical therapy with drugs such as meropenem in combination with vancomycin for E. faecium was not associated with in-hospital mortality, duration of ICU stay, and duration of ventilator support, after adjusting for confounding factors.

Nationwide observational study of mortality from complicated intra-abdominal infections and the role of bacterial cultures.

BACKGROUND: The benefit of taking intra-abdominal cultures during source control procedures in patients with complicated intra-abdominal infection (CIAI) is unknown. The aim of this study was to evaluate whether intra-abdominal cultures reduce the mortality rate of CIAI. METHODS: The Japanese Diagnosis Procedure Combination database was used to identify adult patients with CIAI who had undergone source control procedures on the first day of admission to hospital between April 2014 and March 2016. In-hospital mortality was compared between patients who did and those who did not have intra-abdominal cultures taken. A generalized linear mixed-effect logistic regression model and a random intercept per hospital were used to adjust for baseline confounders and institutional differences. Subgroup analyses were also performed according to disease cause, site of onset and severity of CIAI. RESULTS: Intra-abdominal cultures were taken from 16 303 of 41 495 included patients. Multivariable logistic regression analysis showed that patients with intra-abdominal cultures had a significantly lower mortality than those without (odds ratio 0·85, 95 per cent c.i. 0·77 to 0·95). Subgroup analyses revealed statistically significant differences in mortality between patients with and without cultures among those with lower intestinal perforation, biliary tract infection/perforation, healthcare-associated CIAI and high-risk community-acquired CIAI. CONCLUSIONS: Intra-abdominal cultures obtained during source control procedures may reduce in-hospital mortality, especially in patients with lower intestinal perforation, biliary tract infection/perforation, or healthcare-associated or high-risk community-acquired CIAI.

Multiple small bowel perforations due to invasive aspergillosis in a patient with acute myeloid leukemia: case report and a systematic review of the literature.

PURPOSE: Invasive aspergillosis (IA) represents a major cause of morbidity and mortality in immunocompromised patients. Involvement of the gastrointestinal tract by Aspergillus is mostly reported as part of a disseminated infection from a primary pulmonary site and only rarely as an isolated organ infection. METHODS: We report a case of small bowel perforation due to IA in a patient with acute leukemia under chemotherapy and pulmonary aspergillosis. We performed a systematic review of the literature as well. RESULTS: A 43-year-old man with acute myeloid leukemia under chemotherapy developed severe neutropenia and pulmonary aspergillosis due to Aspergillus flavus. He developed melena and hemodynamic failure and a contrast-enhanced ultrasound scan suggested active intestinal bleeding. During emergency laparotomy we found multiple intestinal abscesses, several perforations of intestinal loop and Aspergillus flavus was isolated from the abscesses. Resection of the jejunum was performed. The patient received voriconazole and finally recovered. The patient is now alive and in complete disease remission. From literature review we found 35 intestinal IA previously published in single case reports or small case series as well. CONCLUSION: Clinical manifestations of gastrointestinal aspergillosis are nonspecific, such as abdominal pain, and only occasionally it presents as an acute abdomen. Antemortem detection of bowel involvement is rarely achieved and, only in cases of complicated gastrointestinal aspergillosis, the diagnosis is achieved thanks to the findings during surgery. Gastrointestinal aspergillosis should be suspected in patients with severe and prolonged neutropenia with or without pulmonary involvement in order to consider the right therapy and prompt surgery.

Idiopathic Double Perforation of the Gastrointestinal Tract.

A 73-year old woman was operated on with diffuse peritonitis and multiple abscesses throughout the mesentery which were drained. After the operation the patient could not recover. After an indicative computerized tomography the patient was re-explored. Perforation of the ileum and gastric perforation at the pylorus were found. There was no history of underline disease. The double perforation of the GI tract was surgically managed but the patient's course was fatal.

Protective role of the neuropeptide urocortin II against experimental sepsis and leishmaniasis by direct killing of pathogens.

We currently face an alarming resurgence in infectious diseases characterized by antimicrobial resistance and therapeutic failure. This has generated the urgent need of developing new therapeutic approaches that include agents with nontraditional modes of action. A recent interest focused on approaches based on our natural immune defenses, especially on peptides that combine innate antimicrobial activity against diverse pathogens and immunoregulatory functions. In this study, to our knowledge, we describe for the first time the antimicrobial activity of the neuropeptide urocortin II (UCNII) against a panel of Gram-positive and Gram-negative bacteria and tropical parasites of the genus Leishmania. Importantly, this cytotoxicity was selective for pathogens, because UCNII did not affect mammalian cell viability. Structurally, UCNII has a cationic and amphipathic design that resembles antimicrobial peptides. Using mutants and UCNII fragments, we determined the structural requirements for the interaction between the peptide and the surface of pathogen. Following its binding to pathogen, UCNII caused cell death through different membrane-disrupting mechanisms that involve aggregation and membrane depolarization in bacteria and pore formation in Leishmania. Noteworthily, UCNII killed the infective form of Leishmania major even inside the infected macrophages. Consequently, UCNII prevented mortality caused by polymicrobial sepsis and ameliorated pathological signs of cutaneous leishmaniasis. Besides its presence in body physical and mucosal barriers, we found that innate immune cells produce UCNII in response to infections. Therefore, UCNII could be considered as an ancient highly-conserved host peptide involved in the natural antimicrobial defense and emerge as an attractive alternative to current treatments for microbial disorders with associated drug resistances.

Prevalence, morbidity, and mortality patterns of typhoid ileal perforation as seen at the University of Nigeria Teaching Hospital Enugu Nigeria: an 8-year review.

BACKGROUND: Some recent studies have reported a decrease in mortality from typhoid ileal perforation. The present report aims to determine the prevalence, morbidity, and mortality of this disease in patients mostly drawn from a rural area. METHODS: This is a retrospective study of 50 patients treated between January 1999 and December 2007 at the University of Nigeria Teaching Hospital, Enugu, Nigeria. The variables studied included patient demographics, clinical features, intraoperative findings, complications, and mortality. Statistical analysis was done with SPSS version 13. RESULTS: Of the 50 patients included in the study, 22 were males with the highest rate in patients aged 20 years and younger. Fever was the commonest symptom and at initial presentation, the mean pulse and respiratory rates were significantly higher in the patients who subsequently died than in those who survived (P < 0.05). All the perforations occurred in the ileum; 62 % of the patients had solitary perforations, 28 % had double perforations, and 10 % had three or more. Fifty-eight perforations were treated by simple closure in two layers, 4 patients had ileal resection and anastomosis, and 2 underwent right hemicolectomy. The mean interval between operation and death was 1.7 days. The overall mortality rate was 30 %, but among those with three or more perforations, mortality was 100 %. CONCLUSIONS: Typhoid ileal perforation still carries a high mortality especially in rural areas. Those with tachycardia and tachypnea at presentation and those with three or more perforations are at a higher risk of dying from the disease.

Typhoid glomerulonephritis and intestinal perforation in a Nigerian child.

The number of children with renal complications following salmonella infection cannot be precisely defined in the sub-Saharan Africa due to scarcity of reliable data. We report a 3-year-old boy with glomerulonephritis secondary to typhoid infection and later intestinal perforation. He presented with fever, generalized body swelling, oliguria, coke- colored urine and hypertension and had been managed 3 weeks earlier for typhoid fever in a private hospital. Laboratory investigations showed proteinuria, hematuria with red cell casturia and azotemia. Abdominal X-ray done was suggestive of typhoid intestinal perforation that was confirmed at exploratory laparotomy. He was managed aggressively with antibiotics and was discharged on the 25 th day of admission. To the best of our knowledge, this is the first documented case report of acute glomerulonephritis and intestinal perforation as co-complications of salmonella infection in Nigeria.

Mucormycosis presenting as intestinal perforation: A pathologist perspective.

Mucormycosis is a life-threatening fungal infection mostly involving the ocular region, sinuses and brain. It is mostly seen in the immunocompromised host. Gastrointestinal (GI) mucormycosis is rare and mostly present as hematemesis, abdominal pain and melena. Here, we present a case of intestinal mucormycosis who presented as cecal perforation. Surgical resection was done, and the diagnosis was made by histopathology. Our case is unique in the way that GI mucormycosis is itself a rare entity and even rarer in an immunocompetent host.

Disseminated Histoplasmosis Causing Temporally and Spatially Discrete Gastrointestinal Perforations in an HIV-Negative Patient.

Histoplasma capsulatum is a dimorphic fungi endemic to the Ohio and Mississippi River valleys. Immunocompetent persons who become infected are generally asymptomatic or present with mild symptoms. Symptomatic disease is seen primarily in immunocompromised patients with pulmonary manifestations being the most common presentation. We present a case of a young HIV-negative male who required 4 exploratory laparotomies over the course of 4 months during 2 hospitalizations due to discrete perforations of the ileum and jejunum caused by biopsy-proven gastrointestinal histoplasmosis despite maximal medical therapy as well as a gastric perforation.

Gallbladder perforation complicating typhoid fever: report of two cases.

BACKGROUND: Gallbladder perforation (GBP) is rare and as a complication of typhoid fever is extremely rare. We present two consecutive patients with GBP diagnosed incidentally at laparotomy. METHOD: Information on the management of two patients with gallbladder perforation seen at Federal Medical Centre Azare in June and October 2008 was extracted from their case records. RESULTS: The two patients were both males aged 13 years and 16 years. They both presented with high fever of more than 2 weeks duration; and abdominal pain and distension. Both patients had features of generalised peritonitis. Pre-operative diagnoses of typhoid enteric perforation were made based on a positive Widal test. Intra-operative findings however, were that of bile peritonitis and gallbladder perforation. Both had cholecystectomy. Culture of the bile aspirate yielded Salmonella typhi. CONCLUSION: Gallbladder perforation secondary to typhoid fever should be considered as a differential diagnosis in patients with suspected typhoid enteric perforation in typhoid fever endemic region.

Stillbirth as the primary manifestation of disseminated tuberculosis in a young immunocompetent mother with multiple perforations of the ileum.

Tuberculosis (TB), a significant cause of morbidity and mortality worldwide, is particularly relevant in low/middle-income countries like India, where the disease is endemic. The female reproductive system is very vulnerable to this infection with, the clinical presentation being utterly silent in most patients. Symptoms of TB in pregnancy may initially be attributed to the gravidity itself besides temporary concealment of associated weight loss by the normally occurring weight gain during the pregnancy. Untreated TB may cause pregnancy loss by either placental damage or direct harm to both the mother and child. We report a case of latent disseminated TB in a young immunocompetent female that was revealed in the postpartum state (after full-term stillbirth delivery at home) as 20 ileal perforations secondary to intestinal TB. Due to ongoing sepsis and delayed presentation to the hospital, the patient could not be salvaged despite the best possible efforts.

Bowel obstruction and perforation during pregnancy: Case report and literature review.

OBJECTIVE: Bowel perforation during pregnancy is a rare but life-threatening situation, and the management remained uncertain. We presented a case in our hospital and reviewed literatures to provide a guidance to deal with this challenging situation. CASE REPORT: A case at gestational age 26 weeks and 4 days, who had bowel perforation over previous ileo-colonic anastomosis site. The fetus was delivered via cesarean section after 1 week of operation and both were discharged without major complication at 35 days after delivery. We searched Pubmed and reviewed 15 English literatures and make a discussion. CONCLUSION: A simultaneous cesarean section could be considered if the gestational age was large enough to avoid the comorbidity of preterm birth or the maternal risk of sepsis outweigh the risk of preterm birth. Otherwise, tocolysis should be used in an attempt to delay delivery until the antenatal corticosteroids have worked.

A Novel Presentation of Tuberculosis with Intestinal Perforation in a Free-Ranging Australian Sea Lion (Neophoca cinerea).

We detail a novel presentation of tuberculosis associated with intestinal perforation in an endangered Australian sea lion (Neophoca cinerea) from South Australian waters and confirm the presence of this disease in the region of highest pup production. In February 2017, a 3-yr-old juvenile male died shortly after hauling out at the Kingscote beach on Kangaroo Island. On postmortem examination, we found a mid-jejunal intestinal perforation and partial obstruction (from a strangulating fibrous and granulomatous mesenteric mass), a marked multicentric abdominal fibrosing granulomatous lymphadenitis, and a large volume serosanguinous peritoneal effusion. Acid-fast bacteria were detected postmortem in cytologic preparations of the mesenteric lymph node and in histologic sections of jejunum and the encircling mass. Mycobacterial infection was confirmed by positive culture after 3 wk. Molecular typing using mycobacterial interspersed repetitive-unit-variable-number tandem-repeat typing with 12-locus analysis identified Mycobacterium pinnipedii. This case highlights the need for vigilance of zoonotic disease risk when handling pinnipeds, including in the absence of specific respiratory signs or grossly apparent pulmonary pathology. Increased serologic population surveillance is recommended to assess the species' risk from this and other endemic diseases, especially given its endangered status.

Primary tubercular caecal perforation: a rare clinical entity.

BACKGROUND: Intestinal tuberculosis is a common problem in endemic areas, causing considerable morbidity and mortality. An isolated primary caecal perforation of tubercular origin is exceptionally uncommon. CASE PRESENTATION: We report the case of a 39 year old male who presented with features of perforation peritonitis, which on laparotomy revealed a caecal perforation with a dusky appendix. A standard right hemicolectomy with ileostomy and peritoneal toileting was done. Histopathology revealed multiple transmural caseating granulomas with Langerhans-type giant cells and acid-fast bacilli, consistent with tuberculosis, present only in the caecum. CONCLUSIONS: We report this extremely rare presentation of primary caecal tuberculosis to sensitize the medical fraternity to its rare occurrence, which will be of paramount importance owing to the increasing incidence of tuberculosis all over the world, especially among the developing countries.

Effectiveness of endotoxin scattering photometry for determining the efficacy of polymyxin B-immobilized fiber treatment in septic shock: report of a case.

The limulus test, which has been established as a test for endotoxin measurement, is associated with problems, including that posed by the presence of a response inhibitor factor and the longer time needed for the measurement of low concentrations. On the other hand, the technique of direct hemoperfusion with a polymyxin B immobilized fiber column (DHP-PMX) was developed in Japan in 1994 and has been used for the control of endotoxemia in septic shock. The limulus test, which is a common endotoxin measurement test, has several problems with regard to sensitivity. Therefore, this test is no longer used to determine the effectiveness of DHP-PMX. Here, we describe a patient presenting with colonic perforation who recovered from septic shock with DHP-PMX. This treatment effect was reflected by a decrease in plasma endotoxin levels as demonstrated more readily with endotoxin scattering photometry assay than with the standard limulus test. We conclude that endotoxin measurement with endotoxin scattering photometry is superior to nephelometry in patients with endotoxemia.

Intestinal candidiasis: an uncommon cause of necrotizing enterocolitis (NEC) in neonates.

Candida albicans produces intestinal perforation and necrotizing enterocolitis (NEC) in preterm newborns. We reviewed pathology files in neonates with a diagnosis of NEC (10-year period), gathered history, and reviewed histological materials. Of 249 autopsies, two (0.8%) had systemic candidiasis. From 66 surgical cases with a diagnosis of NEC, five cases (7.5%) had intestinal candidiasis. Candida albicans grew in pre- and post-mortem blood, lung, or peritoneal fluid in all cases. Histologically, the small bowel revealed fungi, sometimes intravascular. Systemic candidiasis with intestinal involvement is an important complication of prematurity and a prevalent cause of sepsis. The presence of intraluminal fungi with associated vascular occlusion may lead to bowel ischemia, necrosis, and perforation.

[Typhoid intestinal perforation in children: renewed interest in the Veillard technique in tropical zones]. / Les perforations typhiques du grêle chez l'enfant: un regain d'intérêt de la technique de Veillard en milieu tropical.

GOAL: to value the results of the ileo colic intubation of Veillard in relation to the resection anastomosis and the ileostomy. PATIENT AND METHOD: It is about a randomised survey on 12 months (January 1st to December 31st, 2006). This study took place in the St. Jean de Dieu hospital of Afagnan. It was about children aged of less than 15 years having presented more a perforation of bowel. The diagnostic methods of the spindly shackle perforation were clinics and radiographic. It is about an observational randomized study in simple insu for the choice of the technique (resection anastomosis or ileostomy and ileo colic intubation). It was about a choice with two arms: ileo colic intubation versus resection anastomosis and ileostomy. The realization of the resection anastomosis or the ileostomy was left to the choice of the surgeon. Forty patients have been drawn by lot and have been distributed in tow groups: Group A (ileo colic intubation), group B (resection - anastomosis and ileostomy). The patients were distributed in 28 boys (70%) with 20 boys in the group A and 8 in group B and 12 girls (30%) with 8 girls in group A and 4 in group B whose middle age was of 8 years and 5 months (ranges: 4 to 14 years). The middle age were 8 years 10 months (ranges: 4 to 14 years) in group A and 8 years (ranges: 5 to 13 years) in group B. In operative meadow, a standard antibiotherapy was instituted in all patients: Ciprofloxacin and Metronidazole in 24 patients (60%), and Ceftriaxone and Metronidazole in 16 patients (40%). We have used the statistic test of KHI2 with a threshold 5% for statistical analysis. RESULTS: The ileo colic intubation technique has been practiced 22 times (55%), the resection - anastomosis technique has been practiced 15 times (37.5%) and the ileostomy technique has been practiced three times (7.5%). The middle length of hospitalization of the patients was of 15 days (ranges: 10 to 45 days) with 13 days (ranges: 10 to 25 days) in group A and 19 days (ranges: 15 to 45 days in group B. The post operative complications were significantly more frequent with the resection anastomosis (53.3%) than with ileo colic intubation (4.5%). CONCLUSION: The ileo colic intubation still rivets an interest in the intestinal typhoid perforation in tropical environment.