[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.

[TERTIARY PERITONITIS]. / PERITONITIS TERCIARIA.

Tertiary peritonitis is an intraabdominal infection that arises in some patients with secondary peritonitis, despite receiving appropriate treatment. Recently described, it is a syndrome of late peritonitis and we are still lacking a precise and widely adopted definition. Diagnosis is difficult and treatment is complex. Among other therapeutic efforts, this entity requires early and repeated surgical treatment, either on demand or scheduled laparotomy, or even laparostomy. Prognosis is poor, and mortality can reach up to 60% of patients. We present the most interesting aspects of this disease.

Role of K1 capsule antigen in cirrhotic patients with Escherichia coli spontaneous bacterial peritonitis in southern Taiwan.

Spontaneous bacterial peritonitis (SBP) is one of the most serious complications in patients with cirrhosis. This study aimed to investigate the prevalence of SBP caused by Escherichia coli isolates with or without the K1 capsule antigen in cirrhotic patients and the outcome. From January 2004 to January 2012, a total of 54 and 41 E. coli strains derived from patients with SBP and intestinal perforation (IP), respectively, were included for comparison in this study. Bacterial characteristics including phylogenetic groups, K1 capsule antigen, and 14 virulence factor genetic determinants, as well as data regarding patient characteristics, clinical manifestations, and in-hospital deaths, were collected and analyzed. The prevalence of the K1 capsule antigen gene neuA was more common in SBP isolates compared to IP isolates (28 % vs. 10 %, p = 0.0385). Phylogenetic groups B2 and group D were dominant in E. coli isolates with and without the K1 capsule antigen, respectively. The prevalence of virulence factors genes papG II, ompT, and usp was higher in E. coli K1 strains. There were 26 deaths (48 %) during hospitalization. Presence of the K1 capsule antigen in E. coli isolates was significantly associated with in-hospital death in cirrhotic patients with SBP (42 % vs. 14 %, p = 0.0331). This study demonstrates a higher prevalence of the K1 capsule antigen in E. coli SBP compared to E. coli peritonitis caused by IP. There were significant associations between the K1 capsule antigen and in-hospital mortality and bacterial virulence in cirrhotic patients with E. coli SBP.

[Tertiary peritonitis: as difficult to define as it is to treat]. / Peritonitis terciaria: tan difícil de definir como de tratar.

Tertiary peritonitis is the most delayed and severe outcome of patients with complicated intra-abdominal infections. The major difficulty lies in giving a common, precise and consensus definition in order to know when to make its diagnosis and how it can be avoided and/or treated. This condition requires early and repeated surgery, wide spectrum antibiotic therapy against multi-resistant bacteria and intensive systemic support measures. Despite all this, the prognosis is extremely poor since it has a mortality which can reach up to 60%, with preventions being the most important measure to avoid it developing. In this article, we have made a specific review of tertiary peritonitis, of the accepted definitions, the risk factors, its pathophysiology, the microbiological flora involved, and its treatment.

Analysis of bovine postmortem condemnation data in France: Contributions from a comprehensive and standardised information system at the slaughterhouse.

BACKGROUND: The condemnation of carcases and offal unfit for human consumption is a regulatory requirement at the slaughterhouse. Condemnation data, if comprehensive and standardised, can be a valuable source of information for risk-based inspection and decision making. METHODS: The aim of this study was to analyse postmortem condemnation data that were recorded in all bovine slaughterhouses in mainland France from 1 January 2016 to 31 December 2020 in a comprehensive and standardised information system. The rates of and reasons for condemnation, as well as factors influencing rate variation, were investigated through descriptive analysis and multivariable logistic regression models. RESULTS: The global, total and partial condemnation rates were 4.5%, 0.7% and 3.8% for adult cattle and 1.4%, 0.3% and 1.1% for calves, respectively. Reasons for condemnation varied with the animal category; for example, the three main reasons for total condemnation in adult cattle were serous infiltration of connective tissue (49% of condemned animals), congestive peritonitis (12.2%) and fibrinous peritonitis (10.9%), whereas the top three reasons for partial condemnation were unique abscess (21.9%), haemorrhagic infiltration (20.6%) and muscular sclerosis (17.4%). Condemnation rates were influenced by animal-related factors (sex, age, type of breed) and slaughterhouse-related factors (status, type, slaughter volume). CONCLUSION: Our findings could usefully contribute to the continuous improvement of the harmonisation of inspection decisions and support the risk manager's strategy in the modernisation of official controls at the slaughterhouse.

Preoperative CT staging in sigmoid diverticulitis--does it correlate with intraoperative and histological findings?

PURPOSE: This study was designed to evaluate whether the computed tomography (CT) reflects the extent of the inflammation in sigmoid diverticulitis (SD) in order to draw conclusions for selecting the appropriate treatment. METHODS: Two hundred four patients who underwent resection for SD from January 2003 to December 2008 were included. The preoperative CT stage was compared with intraoperative and histological findings. Patients were classified into phlegmonous (Hansen-Stock IIa), abscess-forming (HS IIb), and free perforated (HS IIc) forms of SD. Patients with a recurrent type of diverticulitis were excluded. RESULTS: In the phlegmonous type (HS IIa; n = 75), we found a correlation with the preoperative stage in 52% (intraoperative) and 56% (histological), an understaging in 12% (intraoperative) and 11% (histological), and an overstaging in 36% (intraoperative) and 33% (histological). In the abscess-forming type (HS IIb, Hinchey I/II; n = 87), we found conformity in 92% (intraoperative) and 90% (histological), understaging in 3% (intraoperative) and 0% (histological), and overstaging in 5% (intraoperative) and 10% (histological). In the presence of a free perforation (HS IIc, Hinchey III/IV; n = 42), we saw conformity in 100% (intraoperative and histological). The positive predictive value for correctly diagnosing of phlegmonous type (HS IIa), abscess-forming type (HS IIb), and free perforation (HS IIc) by CT was intraoperatively (histologically) 52% (56), 92% (90), and 100% (100), respectively. CONCLUSIONS: The CT is one of the most accurate methods for staging in SD. However, in the phlegmonous type (HS IIa), it leads to an overestimation of the findings in every third patient. It must be clarified whether this pronounced low inflammation should really be regarded as a complicated form of SD. In contrast, the abscess-forming (HS IIb) and free perforated (HS IIc) type of complicated SD is very well reflected by CT.

[What should and should not be covered in intraabdominal infection]. / Lo que hay que cubrir y lo que no hay que cubrir en la infección intraabdominal.

Despite improvements in our knowledge of the physiopathology of severe infection, diagnostic methods, antibiotic therapy, postoperative care and surgical techniques, a substantial number of patients with intraabdominal infection (IAI) will develop advanced stages of septic insult requiring admission to the intensive care unit. The success of treatment of IAI is multifactorial and the best antibiotic protocol may be insufficient unless adequate control of the focus of infection has been achieved. The present article discusses the appropriacy of empirical antibiotic therapy and the main pathogens associated with treatment failure. We also analyze the patients at risk of infection with microorganisms requiring broad-spectrum antimicrobial coverage. However, excessive antibiotic treatment, in terms of either spectrum or duration, could jeopardize future patients in an environment already threatened by the scarcity of research and development into new molecules required for the emergence of pathogens resistant to current antibiotics.

Mannheim Peritonitis Index and APACHE II--prediction of outcome in patients with peritonitis.

BACKGROUND: Early prognostic evaluation of patients with peritonitis is desirable to select high-risk patients for intensive management and also to provide a reliable objective classification of severity and operative risk. This study attempts to evaluate the use of scoring systems such as Acute Physiological and Chronic Health Evaluation score (APACHE II) and Mannheim Peritonitis Index (MPI) in patients with peritonitis. METHODS: A prospective study was conducted using 101 consecutive patients (69 male, 32 female) having generalized peritonitis over a two-year period. Both scoring systems were applied to patients before laparotomy. Based upon the scores, patients were arranged into three groups. The outcome of patients was noted and the accuracy of the two systems was evaluated. RESULTS: In the MPI system, mortality was 0 in the group of patients with a score of less than 15, while it was 4% in the patients scoring 16-25 and 82.3% in those with scores of more than 25. Similarly, in the APACHE II system, no mortality was noted in patients with scores less than 10. Mortality was 35.29% and 91.7% in the groups scoring 10-20 and more than 20, respectively. CONCLUSION: Both scoring systems are accurate in predicting mortality; however, the APACHE II has definitive advantages and is therefore more useful.

The Bucharest ESTES consensus statement on peritonitis.

INTRODUCTION: Peritonitis is still an important health problem associated with high morbidity and mortality. A multidisciplinary approach to the management of patients with peritonitis may be an important factor to reduce the risks for patients and improve efficiency, outcome, and the cost of care. METHODS: Expert panel discussion on Peritonitis was held in Bucharest on May 2017, during the 17th ECTES Congress, involving surgeons, infectious disease specialists, radiologists and intensivists with the goal of defining recommendations for the optimal management of peritonitis. CONCLUSION: This document is an updated presentation of management of peritonitis and represents the summary of the final recommendations approved by a panel of experts.

[Intra-abdominal infections: definitions and classification]. / Infezioni intraddominali: ambiti e definizioni.

Intraabdominal infections (IAIs) represent a wide variety of pathological conditions that involve lesions of all the intra-abdominal organs. They include both inflammation of single organs and any sort of peritonitis (primary, secondary, tertiary), where the severity of the disease often depends from the extension of the inflammation ((local or diffuse peritonitis). They include also the intra-peritoneal, retroperitoneal and parenchymal abscesses. The aim of current review is that of analyse the current definitions and classifications of intraabdominal infections.

Getting the invite list right: a discussion of sepsis severity scoring systems in severe complicated intra-abdominal sepsis and randomized trial inclusion criteria.

Background: Severe complicated intra-abdominal sepsis (SCIAS) is a worldwide challenge with increasing incidence. Open abdomen management with enhanced clearance of fluid and biomediators from the peritoneum is a potential therapy requiring prospective evaluation. Given the complexity of powering multi-center trials, it is essential to recruit an inception cohort sick enough to benefit from the intervention; otherwise, no effect of a potentially beneficial therapy may be apparent. An evaluation of abilities of recognized predictive systems to recognize SCIAS patients was conducted using an existing intra-abdominal sepsis (IAS) database. Methods: All consecutive adult patients with a diffuse secondary peritonitis between 2012 and 2013 were collected from a quaternary care hospital in Finland, excluding appendicitis/cholecystitis. From this retrospectively collected database, a target population (93) of those with either ICU admission or mortality were selected. The performance metrics of the Third Consensus Definitions for Sepsis and Septic Shock based on both SOFA and quick SOFA, the World Society of Emergency Surgery Sepsis Severity Score (WSESSSS), the APACHE II score, Manheim Peritonitis Index (MPI), and the Calgary Predisposition, Infection, Response, and Organ dysfunction (CPIRO) score were all tested for their discriminant ability to identify this subgroup with SCIAS and to predict mortality. Results: Predictive systems with an area under-the-receiving-operating characteristic (AUC) curve > 0.8 included SOFA, Sepsis-3 definitions, APACHE II, WSESSSS, and CPIRO scores with the overall best for CPIRO. The highest identification rates were SOFA score ≥ 2 (78.4%), followed by the WSESSSS score ≥ 8 (73.1%), SOFA ≥ 3 (75.2%), and APACHE II ≥ 14 (68.8%) identification. Combining the Sepsis-3 septic-shock definition and WSESSS ≥ 8 increased detection to 80%. Including CPIRO score ≥ 3 increased this to 82.8% (Sensitivity-SN; 83% Specificity-SP; 74%. Comparatively, SOFA ≥ 4 and WSESSSS ≥ 8 with or without septic-shock had 83.9% detection (SN; 84%, SP; 75%, 25% mortality). Conclusions: No one scoring system behaves perfectly, and all are largely dominated by organ dysfunction. Utilizing combinations of SOFA, CPIRO, and WSESSSS scores in addition to the Sepsis-3 septic shock definition appears to offer the widest "inclusion-criteria" to recognize patients with a high chance of mortality and ICU admission. Trial registration: https://clinicaltrials.gov/ct2/show/NCT03163095; Registered on May 22, 2017.

Exit-Site Infection: A Comparison of Classification Systems.

In general, in peritoneal dialysis (PD) practice in hospitals, Twardowski and Prowant's exit-site classification system is used, while the International Society for Peritoneal Dialysis (ISPD) exit-site scoring system is practical to use in community visits with less experienced healthcare personnel. Nevertheless, when exit-site scoring is 3 points under the ISPD exit-site score system and it falls in the category of equivocal under the Twardowski and Prowant's exit-site classification, the physician should be vigilant about the possibility of developing peritonitis, and hence, patients need to be kept under periodic monitoring.

Management of peritonitis in the critically ill patient.

Severe secondary peritonitis carries significant mortality, despite advancements in critical care support and other therapies. Surgical management requires a multidisciplinary approach to guide the timing and the number of interventions necessary to eradicate the septic foci and create optimal healing with the fewest complications. Research is needed regarding the best surgical strategy for very severe cases. The use of deferred primary anastomosis seems safe in patients presenting with hemodynamic instability and hypoperfusion. These patients have a high risk of anastomotic failure and fistula formation. Allowing for aggressive resuscitation and judicious assessment of the progression of local inflammation are safe strategies to achieve the highest success and minimize serious and protracted complications in patients who survive the initial septic insult.

Primary peritonitis in adults: is it time to look for a better diagnostic classification?

BACKGROUND: The occurrence of primary peritonitis is rare. The experience of a single institution and the definition of this disease are reviewed. METHODS: A retrospective audit of primary peritonitis at a single institution was undertaken. Age, sex, clinical presentation, initial diagnosis, imaging and blood tests, comorbidities, recent medical intervention, surgical treatment and operative findings, antibiosis, bacterial isolates, the course of hospital treatment and follow up, including later diagnoses, were reviewed. RESULTS: The audit was carried out at Christchurch Hospital between January 1998 and March 2005. A total of 115 patients were identified with a diagnosis of non-specific peritonitis, of which five patients were identified with a diagnosis of primary peritonitis. All were women aged 22-38 years. Three had undergone a caesarean section in the last 3 months. The details of these cases are presented in detail. CONCLUSION: Five cases of primary peritonitis are reported, and from a review of published work, a classification of primary peritonitis is suggested, which more clearly identifies the cause of the disease.

Pneumococcal peritonitis in adult patients: report of 64 cases with special reference to emergence of antibiotic resistance.

BACKGROUND: Few data are available regarding pneumococcal peritonitis. We studied the clinical characteristics of intra-abdominal infections caused by Streptococcus pneumoniae and its prognosis in relation to antibiotic resistance. METHODS: We reviewed all cases of culture-proved pneumococcal peritonitis. Patients with liver cirrhosis and primary pneumococcal peritonitis were compared with patients with Escherichia coli peritonitis. RESULTS: Between January 1, 1979, and December 31, 1998, we identified 45 cases of primary pneumococcal peritonitis in patients with cirrhosis and 19 cases of secondary (or tertiary) pneumococcal peritonitis. Patients with cirrhosis and primary pneumococcal peritonitis vs those with primary E coli peritonitis had more frequent community-acquired infection, 73% vs 47%; pneumonia, 36% vs 2%; and bacteremia, 76% vs 33%; and higher attributable mortality (early mortality), 27% vs 9% (P<.05 for all). Secondary (or tertiary) pneumococcal peritonitis was associated with upper or lower gastrointestinal tract diseases; in most cases, the infection appeared after surgery. A hematogenous spread of S pneumoniae from a respiratory tract infection might be the most important origin of peritonitis; also, S pneumoniae might directly reach the gastrointestinal tract favored by endoscopic procedures or hypochlorhydria. There was an increased prevalence of penicillin and cephalosporin resistance up to 30.7% and 17.0%, respectively, although it was not associated with increased mortality rates. CONCLUSIONS: Primary pneumococcal peritonitis in patients with cirrhosis more often spread hematogenously from the respiratory tract and was associated with early mortality. In secondary (and tertiary) pneumococcal peritonitis, a transient gastrointestinal tract colonization and inoculation during surgery might be the most important mechanisms. Current levels of resistance were not associated with increased mortality rates.

Evaluation of Mannheim peritonitis index and multiple organ failure score in patients with peritonitis.

BACKGROUND: Early classification of severity of peritonitis by scoring systems, including the Mannheim peritonitis index (MPI) and the multiple organ failure (MOF) score, modulates surgical and medical management. AIM: To predict outcome of patients with peritonitis using the MPI and MOF scoring systems. METHODS: Prospective evaluation of the MPI and MOF score was performed in 80 consecutive patients with peritonitis who underwent uniform surgical treatment. Risk ratios were calculated for the MPI and other patient characteristics. Risk ratio was not calculable for the MOF score. RESULTS: Overall in-hospital mortality rate was 17.5%, including 80% of patients with MPI>29. In non-survivors the mean score was 4.8 (SD 1.46) and 33.07 (4.81) for the MOF score and MPI, respectively. Survivors had mean MOF score of 0.28 (0.20) and mean MPI of 19.39 (6.68). CONCLUSION: The MPI and MOF score provide simple and objective means to predict the outcome of patients with peritonitis.

[Antibiotic treatment of intra-abdominal and post-surgical infections]. / La terapia delle infezioni intraddominali e delle infezioni chirurgiche.

During the last years we observed a significant decrease of the mortality following the intra-abdominal infections thanks the improvement of surgical techniques and because of the improved approach of antibiotic treatments. The antibiotic therapy for the treatment of intra-abdominal infections greatly varies according to the infection severity. It is, in fact, possible to distinguish the intra-abdominal infections in three different categories. Mild infections should be treated promptly with surgical drainage and a short term therapy with a wide range antibiotic including anaerobes (ampicillin/sulbactam, cefoxitin). Mild-moderate infections which are largely the most frequent in the clinical practice should be also treated with a single drug which include anaerobes in its spectrum. Finally severe infections require a more aggressive therapeutic approach with a combination treatment covering anaerobes (clyndamicin, metronidazole), Gram negative rods (ciprofloxacin, aminoglycosides) and Gram positive cocci (penicillins, cephalosporins) including MRSA (glycopetides) and/or VRE (linezolid). By the surgical point of view the control of intra-abdominal infections can require different procedures such as laparatomy, relaparotomy or less frequently laparostomy (totally or partially open abdomen). A strong synergy between the surgical procedures and antibiotic therapy represents the best way to approach and resolve even the most severe intra-abdominal infections.

[Treatment of acute purulent diverticulitis is still not clarified]. / Valg af behandling af akut, purulent divertikulitis er uafklaret.

Inflammation in colonic diverticula can develop into acute diverticulitis. Treatment varies depending on illness severity. Perforated diverticulitis with faecal peritonitis is treated surgically and Hartmann's procedure is the preferred operation. Peritoneal lavage might be an alternative to resection for purulent peritonitis. However, ongoing randomized trials are awaited to clarify this.

Prognosis in generalized peritonitis. Relation to cause and risk factors.

Generalized peritonitis was assessed in 176 patients, 67 (38%) of whom died. Cases were divided into causative groups: (1) appendicitis and perforated duodenal ulcer, (2) intraperitoneal origin other than appendix or duodenum, and (3) postoperative peritonitis. Mortalities were 10%, 50%, and 60%, respectively. Postoperative peritonitis was characterized by lack of influence of age on outcome, late operation, and more frequent organ failure. Delayed surgery carried a worse prognosis. Organ failure was a risk factor with 76% mortality, and was associated with late operation. Early surgery in organ failure improved survival. More sensitive indicators of early organ dysfunction might improve survival.

APACHE II score and abdominal sepsis. A prospective study.

Therapeutic trials for intra-abdominal sepsis require pretreatment stratification; physiologic scoring has been recently proposed for this purpose. We have prospectively tested the validity of one such scoring system, namely, the Acute Physiology and Chronic Health Evaluation (APACHE II). As part of a larger database, we correlated APACHE II scores with mortality in 100 patients hospitalized for generalized peritonitis or abdominal abscess. Use of steroids was recorded because of our suspicion that steroids increase mortality but blunt the physiologic response to sepsis. Thirty-one patients died, including 12 of 19 patients receiving steroids. Stepwise discriminant analysis revealed that the APACHE II score and steroid use were each independently associated with the rate of mortality. We report a prospective validation of pretreatment APACHE II scoring in abdominal sepsis. Steroid use is an independent risk factor.