Trends, Outcomes, and Economic Implications of Peritoneal Dialysis-Associated Peritonitis Hospitalizations: A National Cohort Study.

INTRODUCTION: Peritoneal dialysis-associated peritonitis (PDAP) is a serious complication of peritoneal dialysis, associated with significant morbidity, modality transition, and mortality. Here, we provide an update on the national burden of this significant complication, highlighting trends in demographics, treatment practices, and in-hospital outcomes of PDAP from 2016 to 2020. METHODS: Utilizing a national all-payer dataset of hospitalizations in the USA, we conducted a retrospective cohort study of adult hospitalizations with a primary diagnosis of PDAP from 2016 to 2020. We analyzed demographic, clinical, and hospital-level data, focusing on in-hospital mortality, PD catheter removal, length of stay, and healthcare expenses. Multivariable logistic regression adjusted for demographic and clinical covariates was employed to identify risk factors associated with adverse outcomes. RESULTS: There was a stable burden of annual PDAP admissions from 2016 to 2020. Healthcare expenditures associated with PDAP were high, totaling over USD 75,000 per admission. Additionally, our data suggest geographic inconsistencies in treatment patterns, with treatment at western and teaching hospitals associated with increased rates of catheter removal relative to northeastern and non-teaching centers and a mean cost of nearly USD 55,000 more in Western states compared to Midwest states. 23.2% of episodes resulted in the removal of the PD catheter. Risk factors associated with adverse outcomes included older age, higher Charlson comorbidity index scores, peripheral vascular disease, and the need for vasopressors. CONCLUSION: PDAP is a major cause of mortality among PD patients, and there is a vital need for future studies to examine the impact of hospital location and teaching status on PDAP outcomes, which can inform treatment practices and resource allocation.

Factors Influencing Seeking and Reaching Care in Patients With Peritonitis in Rwanda.

BACKGROUND: Peritonitis is an emergency which frequently requires surgical intervention. The aim of this study was to describe factors influencing seeking and reaching care for patients with peritonitis presenting to a tertiary referral hospital in Rwanda. METHODS: This was a cross-sectional study of patients with peritonitis admitted to University Teaching Hospital of Kigali. Data were collected on demographics, prehospital course, and in-hospital management. Delays were classified according to the Three Delays Model as delays in seeking or reaching care. Chi square test and logistic regression were used to determine associations between delayed presentation and various factors. RESULTS: Over a 9-month period, 54 patients with peritonitis were admitted. Twenty (37%) patients attended only primary school and 15 (28%) never went to school. A large number (n = 26, 48%) of patients were unemployed and most (n = 45, 83%) used a community-based health insurance. For most patients (n = 44, 81%), the monthly income was less than 10,000 Rwandan francs (RWF) (11.90 U.S. Dollars [USD]). Most (n = 51, 94%) patients presented to the referral hospital with more than 24 h of symptoms. More than half (n = 31, 60%) of patients had more than 4 d of symptoms on presentation. Most (n = 37, 69%) patients consulted a traditional healer before presentation at the health care system. Consultation with a traditional healer was associated with delayed presentation at the referral hospital (P < 0.001). Most (n = 29, 53%) patients traveled more than 2 h to reach a health facility and this was associated with delayed presentation (P = 0.019). The cost of transportation ranged between 5000 and 1000 RWF (5.95-11.90 USD) for most patients and was not associated with delayed presentation (P = 0.449). CONCLUSIONS: In this study, most patients with peritonitis present in a delayed fashion to the referral hospital. Factors associated with seeking and reaching care included sociodemographic characteristics, health-seeking behaviors, cost of care, and travel time. These findings highlight factors associated with delays in seeking and reaching care for patients with peritonitis.

[Influence of a spontaneous bacterial peritonitis, nosocomial infections and acute-on-chronic liver failure on treatment revenues in patients with decompensated cirrhosis in Germany]. / Einfluss einer spontan bakteriellen Peritonitis, nosokomialer Infektionen und eines akut auf chronischen Leberversagens auf die Behandlungserlöse bei Patienten mit dekompensierter Leberzirrhose in Deutschland.

BACKGROUND: The economic effects of spontaneous bacterial peritonitis (SBP), nosocomial infections (nosInf) and acute-on-chronic liver failure (ACLF) have so far been poorly studied. We analyzed the impact of these complications on treatment revenues in hospitalized patients with decompensated cirrhosis. METHODS: 371 consecutive patients with decompensated liver cirrhosis, who received a paracentesis between 2012 and 2016, were included retrospectively. DRG (diagnosis-related group), "ZE/NUB" (additional charges/new examination/treatment methods), medication costs, length of hospital stay as well as different kinds of specific treatments (e. g., dialysis) were considered. Exclusion criteria included any kind of malignancy, a history of organ transplantation and/or missing accounting data. RESULTS: Total treatment costs (DRG + ZE/NUB) were higher in those with nosInf (€â€Š10,653 vs. €â€Š5,611, p < 0.0001) driven by a longer hospital stay (23 d vs. 12 d, p < 0.0001). Of note, revenues per day were not different (€â€Š473 vs. €â€Š488, p = 0.98) despite a far more complicated treatment with a more frequent need for dialysis (p < 0.0001) and high-complex care (p = 0.0002). Similarly, SBP was associated with higher total revenues (€â€Š10,307 vs. €â€Š6,659, p < 0.0001). However, the far higher effort for the care of SBP patients resulted in lower daily revenues compared to patients without SBP (€â€Š443 vs. €â€Š499, p = 0.18). ACLF increased treatment revenues to €â€Š10,593 vs. €6,369 without ACLF (p < 0.0001). While treatment of ACLF was more complicated, revenue per day was not different to no-ACLF patients (€â€Š483 vs. €â€Š480, p = 0.29). CONCLUSION: SBP, nosInf and/or ACLF lead to a significant increase in the effort, revenue and duration in the treatment of patients with cirrhosis. The lower daily revenue, despite a much more complex therapy, might indicate that these complications are not yet sufficiently considered in the German DRG system.

Factors associated with high-cost hospitalization for peritonitis in children receiving chronic peritoneal dialysis in the United States.

BACKGROUND: Although peritonitis causes significant morbidity and mortality in children receiving chronic peritoneal dialysis (CPD), little is known about costs associated with treatment. METHODS: We analyzed 246 peritonitis-related hospitalizations in the USA, linked by the Standardized Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) and Pediatric Health Information Systems (PHIS) databases. Multivariable logistic regression was used to assess the relationship between high-cost hospitalizations (at or above the 75th percentile) and patient characteristics. Multivariable modeling was used to assess differences in the service-line specific geometric mean between (1) high- and low-cost (below the 75th percentile) hospitalizations and (2) fungal versus other types of peritonitis. Wage-adjusted hospitalization charges were converted to estimated costs using reported cost-to-charge ratios to estimate the cost of hospitalization. RESULTS: High-cost hospitalizations were associated with the following: age 3-12 years, Hispanic ethnicity, intensive care unit (ICU) stay, length of stay (LOS), and fungal peritonitis. Whereas absolute standardized cost by service line was significantly different when comparing high- and low-cost hospitalizations, the percentage of total cost by service line was similar in the two groups. Cost per case for fungal peritonitis was higher (p < 0.001) in every service line except pharmacy when compared to other peritonitis cases. The median (IQR) cost of hospitalization for the treatment of peritonitis was $13,655 ($7871, $28434) USD. CONCLUSIONS: Hospitalization-related costs for peritonitis treatment are substantial and arise from a variety of service lines. Fungal peritonitis is associated with high-cost hospitalization.

Risk of Catastrophic Health Expenditure in Rwandan Surgical Patients with Peritonitis.

BACKGROUND: Surgical procedures are cost-effective compared with various medical and public health interventions. While peritonitis often requires surgery, little is known regarding the associated costs, particularly in low- and middle-income countries. The aim of this study was to determine in-hospital charges for patients with peritonitis and if patients are at risk of catastrophic health expenditure. METHODS: As part of a larger study examining the epidemiology and outcomes of patients with peritonitis at a referral hospital in Rwanda, patients undergoing operation for peritonitis were enrolled and hospital charges were examined. The primary outcome was the percentage of patients at risk for catastrophic health expenditure. Logistic regression was used to determine the association of various factors with risk for catastrophic health expenditure. RESULTS: Over a 6-month period, 280 patients underwent operation for peritonitis. In-hospital charges were available for 245 patients. A total of 240 (98%) patients had health insurance. Median total hospital charges were 308.1 USD, and the median amount paid by patients was 26.9 USD. Thirty-three (14%) patients were at risk of catastrophic health expenditure based on direct medical expenses. Estimating out-of-pocket non-medical expenses, 68 (28%) patients were at risk of catastrophic health expenditure. Unplanned reoperation was associated with increased risk of catastrophic health expenditure (p < 0.001), whereas patients with community-based health insurance had decreased risk of catastrophic health expenditure (p < 0.001). CONCLUSIONS: The median hospital charges paid out-of-pocket by patients with health insurance were small in relation to total charges. A significant number of patients with peritonitis are at risk of catastrophic health expenditure.

Cost analysis of laparoscopic lavage compared with sigmoid resection for perforated diverticulitis in the Ladies trial.

BACKGROUND: Laparoscopic peritoneal lavage is an alternative to sigmoid resection in selected patients presenting with purulent peritonitis from perforated diverticulitis. Although recent trials have lacked superiority for lavage in terms of morbidity, mortality was not compromised, and beneficial secondary outcomes were shown. These included shorter duration of surgery, less stoma formation and less surgical reintervention (including stoma reversal) for laparoscopic lavage versus sigmoid resection respectively. The cost analysis of laparoscopic lavage for perforated diverticulitis in the Ladies RCT was assessed in the present study. METHODS: This study involved an economic evaluation of the randomized LOLA (LaparOscopic LAvage) arm of the Ladies trial (comparing laparoscopic lavage with sigmoid resection in patients with purulent peritonitis due to perforated diverticulitis). The actual resource use per individual patient was documented prospectively and analysed (according to intention-to-treat) for up to 1 year after randomization. RESULTS: Eighty-eight patients were randomized to either laparoscopic lavage (46) or sigmoid resection (42). The total medical costs for lavage were lower (mean difference € - 3512, 95 per cent bias-corrected and accelerated c.i. -16 020 to 8149). Surgical reintervention increased costs in the lavage group, whereas stoma reversal increased costs in the sigmoid resection group. Differences in favour of laparoscopy were robust when costs were varied by ±20 per cent in a sensitivity analysis (mean cost difference € - 2509 to -4438). CONCLUSION: Laparoscopic lavage for perforated diverticulitis is more cost-effective than sigmoid resection.

A contemporary approach to the prevention of peritoneal dialysis-related peritonitis in children: the role of improvement science.

Peritonitis is a leading cause of hospitalizations, morbidity, and modality change in pediatric chronic peritoneal dialysis (CPD) patients. Despite guidelines published by the International Society for Peritoneal Dialysis aimed at reducing the risk of peritonitis, registry data have revealed significant variability in peritonitis rates among centers caring for children on CPD, which suggests variability in practice. Improvement science methods have been used to reduce a variety of healthcare-associated infections and are also being applied successfully to decrease rates of peritonitis in children. A successful quality improvement program with the goal of decreasing peritonitis will not only include primary drivers directly linked to the outcome of peritonitis, but will also direct attention to secondary drivers that are important for the achievement of primary drivers, such as health literacy and patient and family engagement strategies. In this review, we describe a comprehensive improvement science model for the reduction of peritonitis in pediatric patients on CPD.

Health economic analysis of laparoscopic lavage versus Hartmann's procedure for diverticulitis in the randomized DILALA trial.

BACKGROUND: Open surgery with resection and colostomy (Hartmann's procedure) has been the standard treatment for perforated diverticulitis with purulent peritonitis. In recent years laparoscopic lavage has emerged as an alternative, with potential benefits for patients with purulent peritonitis, Hinchey grade III. The aim of this study was to compare laparoscopic lavage and Hartmann's procedure with health economic evaluation within the framework of the DILALA (DIverticulitis - LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) trial. METHODS: Clinical effectiveness and resource use were derived from the DILALA trial and unit costs from Swedish sources. Costs were analysed from the perspective of the healthcare sector. The study period was divided into short-term analysis (base-case A), within 12 months, and long-term analysis (base-case B), from inclusion in the trial throughout the patient's expected life. RESULTS: The study included 43 patients who underwent laparoscopic lavage and 40 who had Hartmann's procedure in Denmark and Sweden during 2010-2014. In base-case A, the difference in mean cost per patient between laparoscopic lavage and Hartmann's procedure was €-8983 (95 per cent c.i. -16 232 to -1735). The mean(s.d.) costs per patient in base-case B were €25 703(27 544) and €45 498(38 928) for laparoscopic lavage and Hartmann's procedure respectively, resulting in a difference of €-19 794 (95 per cent c.i. -34 657 to -4931). The results were robust as demonstrated in sensitivity analyses. CONCLUSION: The significant cost reduction in this study, together with results of safety and efficacy from RCTs, support the routine use of laparoscopic lavage as treatment for complicated diverticulitis with purulent peritonitis.

The incidence and economic impact of the Escherichia coli peritonitis syndrome in Dutch poultry farming.

The incidence and economic impact of the Escherichia coli peritonitis syndrome (EPS), characterized by acute mortality, were estimated in chicken egg-producing farms in the Netherlands in 2013. The incidence was significantly higher (P < 0.05) in the meat-sector (35% affected farms) compared to the layer-sector (7% affected farms). In consumption egg-producing farms EPS occurred on 12% of the free range and organic farms, while it was found on 1% and 4% of the cage and barn farms, respectively. Data from four layer and two broiler breeder flocks with EPS were used to estimate the overall economic impact of the disease. Mean numbers of eggs lost were 10 and 11 per hen housed (phh), while mean slaughter weight loss was 0.2 and 0.5 kg phh in the four layer and two broiler breeder flocks, respectively. Total losses including costs of destruction of dead hens, compensated for reduced feed intake due to a smaller flock size, ranged from €0.28 phh (cage farms) to €9.75 phh (grandparent farms) in the layer-sector and from €1.87 phh (parent farms) to €10.73 phh (grandparent farms) in the meat-sector. Antibiotics against EPS were given often and repeatedly especially in the meat-sector. Including the costs of antibiotics, total losses were estimated at €0.4 million, €3.3 million and €3.7 million for the layer-sector, the meat-sector and poultry farming as a whole, respectively. Research focusing on the prevention and treatment of EPS is justified by its severe clinical and economic impact.

[Clinical-economic analysis of antibacterial therapy of acute peritonitis].

Clinic-economic analysis of antibacterial therapy of an acute peritonitis was conducted, using the method of modeling with "the tree of expanses" building. Economic advantages of ertapenem application as a start therapy of an acute peritonitis were proved.

Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals.

Importance: Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Objectives: To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals. Design, Setting, and Participants: This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021. Main Outcomes and Measures: The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient. Results: There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18). Conclusions and Relevance: This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.

Cost-effectiveness evaluation of ertapenem versus piperacillin/tazobactam in the treatment of complicated intraabdominal infections accounting for antibiotic resistance.

OBJECTIVE: To evaluate the cost-effectiveness of ertapenem versus piperacillin/tazobactam in the treatment of community-acquired complicated intraabdominal infections accounting for development of antibiotic resistance in the Dutch setting. METHODS: A decision tree was developed to estimate cost-effectiveness of ertapenem versus piperacillin/tazobactam at different time points after introduction of treatment. Development of resistance was incorporated using a compartment model. Resistance was a function of the eradication rate of pathogens and antibiotic prescription. Model outcomes included quality-adjusted life years (QALYs), direct costs and cost per QALY saved. Microbiological eradication rate, clinical success, and costs were derived from literature. The analyses included pathogens with intrinsic or acquired resistance. RESULTS: The model suggested overall savings of euro355 (95% uncertainty interval euro480; euro1205) per patient when abdominal infections are treated with ertapenem instead of piperacillin/tazobactam. Probabilistic sensitivity analysis found a 94% probability of the incremental cost per QALY saved being within the generally accepted threshold for cost-effectiveness (euro20,000). After 5 years, it is expected that antibiotic resistance with piperacillin/tazobactam has increased with a greater rate compared to ertapenem, and cost-savings with ertapenem are expected to increase to euro672 (euro-232; euro1617). Ertapenem will, in addition, result in greater success rates and in QALY savings (0.17; 0.07-0.30). Alternative scenarios, with lower levels of initial resistance confirm the cost savings with ertapenem. CONCLUSION: Given the underlying assumptions and data used, this evaluation demonstrated that ertapenem is a cost saving and possibly an economically dominant therapy over piperacillin/tazobactam for the treatment of community-acquired intraabdominal infections in The Netherlands.

Economic consequences of failure of initial antibiotic therapy in hospitalized adults with complicated intra-abdominal infections.

BACKGROUND: Initial antibiotic therapy in hospitalized adults with complicated intra-abdominal infection (cIAI) usually is empiric. We explored the economic consequences of failure of such therapy in this patient population. METHODS: Using a large U.S. multi-institutional database, we identified all hospitalized adults admitted between April 1, 2003, and March 31, 2004; who had any cIAI; underwent laparotomy, laparoscopy, or percutaneous drainage of an intra-abdominal abscess ("surgery"); and received intravenous (IV) antibiotics. Initial therapy was characterized in terms of all IV antibiotics received, on the day of or one day before initial surgery. Antibiotic failure was designated on the basis of the need for reoperation or receipt of other IV antibiotics postoperatively. Switches to narrower spectrum agents and changes in regimen prior to discharge with no other evidence of clinical failure were not counted as antibiotic failures. Using multivariable linear regression, duration of IV antibiotic therapy, hospital length of stay, and total inpatient charges were compared between patients who did and did not fail initial therapy. Mortality was compared using multivariable logistic regression. RESULTS: Among 6,056 patients who met the study entrance criteria, 22.4% failed initial antibiotic therapy. Patients who failed received an additional 5.6 days of IV antibiotic therapy (10.4 total days [95% confidence interval 10.1, 10.8] days vs. 4.8 total days [4.8, 4.9] for those not failing), were hospitalized an additional 4.6 days (11.6 total days [11.3, 11.9] vs. 6.9 total days [6.8, 7.0], respectively), and incurred $6,368 in additional inpatient charges ($16,520 [$16,131, $16,919] vs. $10,152 [$10,027, $10,280]) (all, p < 0.01). They also were more likely to die in the hospital (9.5% vs. 1.3%; multivariable odds ratio 3.58 [95% confidence interval 2.53, 5.06]). CONCLUSIONS: Failure of initial IV antibiotic therapy in hospitalized adults with cIAIs is associated with longer hospitalization, higher hospital charges, and a higher mortality rate.

Economic Impact of a Peritoneal Dialysis Continuous Quality Improvement Program in Colombia.

♦ BACKGROUND: There is little information regarding the financial burden of peritonitis and the economic impact of continuous quality improvement (CQI) programs in peritoneal dialysis (PD) patients. The objectives of this study were to measure the costs of peritonitis, and determine the net savings of a PD CQI program in Colombia. ♦ METHODS: The Renal Therapy Services (RTS) network in Colombia, along with Coomeva EPS, provided healthcare resource utilization data for PD patients with and without peritonitis between January 2012 and December 2013. Propensity score matching and regression analysis were performed to estimate the incremental cost of peritonitis. Patient months at risk, episodes of peritonitis pre- and post-CQI, and costs of CQI were obtained. Annual net savings of the CQI program were estimated based on the number of peritonitis events prevented. ♦ RESULTS: The incremental cost of a peritonitis episode was $250. In an 8-year period, peritonitis decreased from 1,837 episodes per 38,596 patient-months in 2006 to 841 episodes per 50,910 patient-months in 2014. Overall, the CQI program prevented an estimated 10,409 episodes of peritonitis. The cost of implementing the CQI program was $147,000 in the first year and $119,000 annually thereafter. Using a five percent discount rate, the net present value of the program was $1,346,431, with an average annual net savings of $207,027. The return on investment (i.e. total savings-program cost/program cost) of CQI was 169%. ♦ CONCLUSION: Continuous quality improvement initiatives designed to reduce rates of peritonitis have a strong potential to generate cost savings.

Switch therapy with ciprofloxacin vs. intravenous ceftazidime in the treatment of spontaneous bacterial peritonitis in patients with cirrhosis: similar efficacy at lower cost.

BACKGROUND: Intravenous administration of a third-generation cephalosporin is optimal antibiotic treatment for spontaneous bacterial peritonitis. AIMS: To compare an intravenous-oral step-down schedule with ciprofloxacin (switch therapy) to intravenous ceftazidime in the treatment of spontaneous bacterial peritonitis, and to evaluate the impact of terlipressin and albumin in the treatment of type 1 hepatorenal syndrome on mortality. METHODS: A total of 116 cirrhotic patients with spontaneous bacterial peritonitis, were randomly given switch therapy with ciprofloxacin (61 patients) or intravenous ceftazidime (55 patients). All patients who developed type 1 hepatorenal syndrome were treated with terlipressin (2-12 mg/day) and albumin (20-40 g/day). RESULTS: Resolution of infection was achieved in 46/55 patients treated with ceftazidime (84%) and in 49/61 patients treated with ciprofloxacin (80%, P = N.S.). An intravenous-oral step-down schedule was possible in 50/61 patients (82%) who received ciprofloxacin; 45/61 patients (74%) were discharged before the end of antibiotic treatment and completed it at home. The mean saving per patient due to the reduction of hospital stay in the ciprofloxacin group was 1150 . Type 1 hepatorenal syndrome was treated successfully in 12/19 patients (63%). As a consequence, the in-hospital mortality rate due to infection was 10%. CONCLUSIONS: Switch therapy with cephalosporin is more cost-effective than intravenous ceftazidime in the treatment of spontaneous bacterial peritonitis in cirrhotic patients who are not on prophylaxis with quinolones.

Beyond perforation: Influence of peritoneal contamination on clinical severity and resource utilization in children with perforated appendicitis.

PURPOSE: The purpose of the study was to explore the relationship between the degree of peritoneal contamination and postoperative resource utilization in children with complicated appendicitis. METHODS: Intraoperative findings were collected prospectively at a single children's hospital from 2012 to 2014. The degree of peritoneal contamination was categorized as either "localized" (confined to the right lower quadrant and pelvis) or "extensive" (extending to the liver). Imaging utilization, postoperative length of stay (pLOS), hospital cost, and readmission rates were compared between groups. RESULTS: Of 88 patients with complicated appendicitis, 38% had extensive contamination. Preoperative characteristics were similar between groups. Patients with extensive contamination had higher rates of postoperative imaging (58.8% vs 27.7%, P<0.01), a 50% longer median pLOS (6days [IQR 4-9] vs 4days [IQR 2-5], P=0.003), a 30% higher median hospital cost ($17,663 [IQR $12,564-$23,697] vs $13,516 [IQR $10,546-$16,686], P=0.004), and a nearly four-fold higher readmission rate (20.6% vs 5.6%, P=0.04) compared to children with localized contamination. CONCLUSION: Extensive peritoneal contamination is associated with significantly higher resource utilization compared to localized contamination in children with complicated appendicitis. These findings may have important severity-adjustment implications for reimbursement and readmission rate reporting for hospitals that serve populations where late presentation is common.

Antibacterial gauzes are effective in preventing infections after percutaneous endoscopic gastrostomy placement: a retrospective analysis.

OBJECTIVES: The most common complication after percutaneous endoscopic gastrostomy (PEG) placement is peristomal wound infection (up to 40% without antibiotic prophylaxis). Single-dose parenteral prophylactic antibiotics as advised by current guidelines decrease the infection rate to 9-15%. We assume a prolonged effect of local antibiotic treatment with antibacterial gauzes. This study is the first to describe the effect of antibacterial gauzes in preventing infections in PEG without the use of antibiotics. METHODS: A retrospective data analysis was carried out of all patients with PEG insertion between January 2009 and October 2014 in the Catharina Hospital Eindhoven. Data include placement and the period of the first 2 weeks after PEG placement, and long-term follow-up. All patients received a locally applied antibacterial gauze polyhexamethylene biguanide immediately following PEG insertion for 3 days. No other antibiotics were administered. The main outcomes were wound infection, peritonitis, and necrotizing fasciitis; secondary outcomes included other complications. RESULTS: A total of 331 patients with only antibacterial gauzes were analyzed. The total number of infections 2 weeks after PEG insertion was 9.4%, including 8.2% minor and 1.2% major infections (peritonitis). No wound infection-related mortality or bacterial resistance was found. Costs are five times lower than antibiotics, and gauzes are more practical and patient friendly for use. CONCLUSION: Retrospectively, antibacterial gauzes are at least comparable with literature data on parenteral antibiotics in preventing peristomal wound infection after PEG placement, with an infection rate of 9.4%. Rates of other complications found in this study were comparable with current literature data.

[New approaches to intensive care for sepsis]. / Intensivmedizinische Aspekte bei Sepsis. Gibt es neue therapeutische Ansätze?

In Germany, the mortality from sepsis remains high, and up to 60,000 patients die from it each year. Thus, sepsis is the third most common cause of death. More deaths occur only from coronary heart disease and acute myocardial infarction. In the last 3-4 years, substantial progress in sepsis therapy has been made. Based on these achievements, there is hope of reducing sepsis mortality by 25% in the next few years. Implementing new medical evidence in this context into daily clinical intensive care remains a major hurdle. The early diagnosis of sepsis prior to the onset of clinical deterioration is of particular interest, because this would increase the possibility of early and specified treatment, which is in turn the major determining factor of mortality in septic patients.

New perspectives in antibiotic prophylaxis for intra-abdominal surgery.

Effective management of intra-abdominal infections requires a combination of preoperative preparation, antibiotic prophylaxis and appropriate surgical technique. Antibacterial prophylaxis should provide coverage of all likely pathogens, including aerobic and anaerobic organisms. Whereas antibacterial combination therapy is appropriate in certain situations, single-agent prophylaxis is appropriate for the majority of patients and ampicillin/sulbactam, with its broad-spectrum anti-aerobic/anti-anaerobic activity, is an attractive prophylactic option. Surgery involving the gastrointestinal tract provides a special challenge by virtue of its high, predominantly anaerobic, bacterial load. However, the requirement for prophylaxis varies depending upon the precise site of intervention. Biliary tract surgery requires prophylaxis in high-risk patients only, whereas hepatobiliary or pancreatic surgery requires prophylaxis in all patients. Gastroduodenal operations require prophylaxis in the presence of risk factors, such as abnormal gastric acidity or bleeding. Colorectal procedures present a high risk of anaerobic infection and sepsis, and require adequate prophylaxis combined with a thorough preoperative preparation designed to reduce considerably the bacterial load of the bowel. Where peritonitis does follow intra-abdominal surgery, patients should receive antibacterial therapy commensurate with the risk of serious infection. A small proportion of patients will be at risk of severe infection and will require triple-agent therapy. However, most patients are likely to develop mild-to-moderate infections only and can be treated with a single, broad-spectrum antibiotic agent, such as ampicillin/sulbactam, a beta-lactam/beta-lactamase inhibitor.

Pharmacoeconomic analysis of ampicillin-sulbactam versus cefoxitin in the treatment of intraabdominal infections.

We conducted a retrospective pharmacoeconomic analysis of a prospective, multicenter, double-blind, randomized, controlled trial comparing the beta-lactamase inhibitor combination ampicillin-sulbactam (96 patients) and the cephalosporin cefoxitin (101) in the treatment of intraabdominal infections. An institutional perspective was adopted for the analysis. The primary outcomes of interest were cure and failure rates, development of new infection, and antibiotic-related adverse events. Epidemiologic data pertaining to outcomes was retrieved primarily from the trial, although results of other published studies were taken into consideration through extensive sensitivity analyses. Data pertaining to potential resource use and economic impact were retrieved mainly from the University Health Consortium and hospital-specific sources. When considering only costs associated with drug acquisition through cost-minimization analysis, a potential savings of $37.24/patient may be realized with ampicillin-sulbactam relative to cefoxitin based on an average 7-day regimen. Outcome data collected for the entire hospitalization during the trial revealed an approximately 9% greater frequency of failure with cefoxitin relative to ampicillin-sulbactam. When considering all outcomes of interest in the initial base-case analysis, a potential cost savings of approximately $890/patient may be realized with ampicillin-sulbactam relative to cefoxitin. In assessing the impact of the significant variability in probability and cost estimates, Monte Carlo analysis revealed a savings of $425/patient for ampicillin-sulbactam over cefoxitin (95% CI -$618 to $1516 [corrected]). Given the model assumptions, our analysis suggests a 78% certainty level that savings will be experienced when ampicillin-sulbactam is chosen over cefoxitin.