Next-generation microbiological testing in intraabdominal infections with PCR technology.

PURPOSE: Intraabdominal infections (IAI) are increasing worldwide and are a major contributor to morbidity and mortality. Among IAI, the number of multi-drug resistant organisms (MDRO) is increasing globally. We tested the Unyvero A50® for intraabdominal infections, compared the detected microorganisms and antibiotic resistance, and compared the results with those of routine microbiology. METHODS: We prospectively compared samples obtained from surgical patients using PCR-based Unyvero IAI cartridges against routine microbiology for the detection of microorganisms. Additionally, we identified clinical parameters that correlated with the microbiological findings. Data were analyzed using the t-test and Mann-Whitney U test. RESULTS: Sixty-two samples were analyzed. The PCR system identified more microorganisms, mostly Bacteroides species, Escherichia coli, and Enterococcus spp. For bacterial resistance, the PCR system results were fully concordant with those of routine microbiology, resulting in a sensitivity, specificity, and positive and negative predictive value (PPV, NPV) of 100%. The sensitivity, specificity, PPV, and NPV for the detection of microorganisms were 74%, 58%, 60%, and 72%, respectively. CRP levels were significantly higher in patients with detectable microorganisms. We identified more microorganisms and bacterial resistance in hospital-acquired intra-abdominal infections by using the PCR system. DISCUSSION: IAI warrants early identification of the microorganisms involved and their resistance to allow for adequate antibiotic therapy. PCR systems enable physicians to rapidly adjust their antibiotic treatment. Conventional microbiological culture and testing remain essential for determining the minimal growth inhibition concentrations for antibiotic therapy.

Time to positivity of Klebsiella pneumoniae in blood cultures as prognostic marker in patients with intra-abdominal infection: A retrospective study.

Klebsiella pneumoniae is a common causative pathogen of intra-abdominal infection with concomitant bacteraemia, leading to a significant mortality risk. The time to positivity (TTP) of blood culture is postulated to be a prognostic factor in bacteraemia caused by other species. Therefore, this study aimed to investigate the prognostic value of TTP in these patients. The single-centred, retrospective, observational cohort study was conducted between 1 July 2016 and 30 June 2021. All adult emergency department patients with diagnosis of intra-abdominal infection and underwent blood culture collection which yield K. pneumoniae during this period were enrolled. A total of 196 patients were included in the study. The overall 30-day mortality rate was 12.2% (24/196), and the median TTP of the studied cohort was 12.3 h (10.5-15.8 h). TTP revealed a moderate 30-day mortality discriminative ability (area under the curve 0.73, p < 0.001). Compared with the late TTP group (>12 h, N = 109), patients in the early TTP (≤12 h, N = 87) group had a significantly higher risk of 30-day morality (21.8% vs. 4.6%, p < 0.01) and other adverse outcomes. Furthermore, TTP (odds ratio [OR] = 0.79, p = 0.02), Pitt bacteraemia score (OR = 1.30, p = 0.03), and implementation of source control (OR = 0.06, p < 0.01) were identified as independent factors related to 30-day mortality risk in patients with intra-abdominal infection and K. pneumoniae bacteraemia. Therefore, physicians can use TTP for prognosis stratification in these patients.

Extra-abdominal infections caused by Comamonas kerstersii: Case report.

RATIONALE: Comamonas kerstersii mainly causes intra-abdominal infections with favorable outcomes due to high antibiotic susceptibility. We report the first case of pneumonia caused by C Kerstersii, which promoted patient death, and a second urinary tract infection by C Kerstersii with extensive drug resistance. PATIENT CONCERNS: A 46-year-old male (Case 1) with craniocerebral injury underwent emergency decompressive craniectomy, but his condition deteriorated further and presented with discontinuous fever, small moist rales on both lungs, and respiratory failure. Retrospective average nucleotide identity (ANI) analysis of the genomic sequence of the sputum isolate identified it as C Kerstersii 12322-1, antimicrobial susceptibility testing (AST) revealed that it was sensitive to 18 of 21 tested antibiotics.An 82-year-old male (Case 2) with hypertrophic prostate experienced gradual obstruction during urination, and a urine test revealed WBC ++. Retrospective ANI analysis of the urine isolate identified it as C Kerstersii 121606, which was resistant to 18 of 21 tested antibiotics. DIAGNOSES: Case 1 was diagnosed empirically as pneumonia caused by C Kerstersii strain 12322-1 secondary to craniocerebral injury and confirmed by retrospective ANI analysis; case 2 was diagnosed empirically as urinary infection secondary to prostate hyperplasia caused by C Kerstersii strain 121606 confirmed by the retrospective ANI analysis. INTERVENTIONS: Case 1 was administered cefoxitin, cefodizime, imipenem-cilastatin sodium, and underwent comprehensive salvage management. Case 2 was administered doxycycline alone. OUTCOMES: Case 1 died partially because of untimely identification of the responsible bacteria-12322-1. Case 2 was cured even 121606 exhibited an extensive drug resistance feature. LESSONS: Except for intra-abdominal infections with good prognosis, we verified that C Kerstersii could also cause extra-abdominal infections, such as the first pneumonia case and urinary infection. It could promote patient death; actual infections were underestimated due to identification difficulties, posing a health threat due to the presence of extensive drug resistance.

Risk factors of acute respiratory distress syndrome in sepsis caused by intra-abdominal infections: A retrospective study.

BACKGROUND: Intra-abdominal infections are frequently associated with acute respiratory distress syndrome, which significantly affects patient prognosis. However, little is known about the specific risk factors of acute respiratory distress syndrome in sepsis caused by intra-abdominal infections. METHODS: This retrospective study included adult patients with intra-abdominal sepsis admitted to the intensive care unit of a tertiary teaching hospital in China between June 2017 and June 2022. Patients were categorized based on the presence or absence of acute respiratory distress syndrome. Data, including vital signs, laboratory values, and severity scores collected within 24 hours of sepsis diagnosis, as well as outcomes within 90 days, were analyzed. Multivariable logistic regression was used to identify independent risk factors associated with acute respiratory distress syndrome. RESULTS: A total of 738 patients were included, of whom 218 (29.5%) developed acute respiratory distress syndrome. Patients with acute respiratory distress syndrome were younger, had a higher body mass index and disease severity scores, and exhibited higher proportions of septic shock and hospital-acquired intra-abdominal infections. The mortalities in the intensive care unit and at 28 and 90 days were higher in the acute respiratory distress syndrome group. In the multivariate logistic regression model, age under 65 years (odds ratio [95% confidence interval]: 1.571 [1.093-2.259]), elevated body mass index (2.070 [1.382-3.101] for overweight, 6.994 [3.207-15.255]) for obesity, septic shock (2.043 [1.400-2.980]), procalcitonin (1.009 [1.004-1.015]), hospital-acquired intra-abdominal infections (2.528[1.373-4.657]), and source of intra-abdominal infections (2.170 [1.140-4.128] for biliary tract infection, 0.443 [0.217-0.904] for gastroduodenal perforation) were independently associated with acute respiratory distress syndrome. CONCLUSION: In patients with intra-abdominal sepsis, age under 65 years, higher body mass index and procalcitonin, septic shock, hospital-acquired intra-abdominal infections, and biliary tract infection were risk factors for acute respiratory distress syndrome.

Development and validation of a nomogram to predict postsurgical intra-abdominal infection in blunt abdominal trauma patients: A multicenter retrospective study.

BACKGROUND: Intra-abdominal infection is a common complication of blunt abdominal trauma. Early detection and intervention can reduce the incidence of intra-abdominal infection and improve patients' prognoses. This study aims to construct a clinical model predicting postsurgical intra-abdominal infection after blunt abdominal trauma. METHODS: This study is a retrospective analysis of 553 patients with blunt abdominal trauma from the Department of General Surgery of 7 medical centers (2011-2021). A 7:3 ratio was used to assign patients to the derivation and validation cohorts. Patients were divided into 2 groups based on whether intra-abdominal infection occurred after blunt abdominal trauma. Multivariate logistic regression and least absolute shrinkage and selection operator regression were used to select variables to establish a nomogram. The nomogram was evaluated, and the validity of the model was further evaluated by the validation cohort. RESULTS: A total of 113 were diagnosed with intra-abdominal infection (20.4%). Age, prehospital time, C-reactive protein, injury severity score, operation duration, intestinal injury, neutrophils, and antibiotic use were independent risk factors for intra-abdominal infection in blunt abdominal trauma patients (P < .05). The area under the receiver operating curve (area under the curve) of derivation cohort and validation cohort was 0.852 (95% confidence interval, 0.784-0.912) and 0.814 (95% confidence interval, 0.751-0.902). The P value for the Hosmer-Lemeshow test was .135 and .891 in the 2 cohorts. The calibration curve demonstrated that the nomogram had a high consistency between prediction and practical observation. The decision curve analysis also showed that the nomogram had a better potential for clinical application. To facilitate clinical application, we have developed an online at https://nomogramcgz.shinyapps.io/IAIrisk/. CONCLUSION: The nomogram is helpful in predicting the risk of postoperative intra-abdominal infection in patients with blunt abdominal trauma and provides guidance for clinical decision-making and treatment.

Combination of serum and peritoneal 1.3-beta-D-glucan can rule out intra-abdominal candidiasis in surgical critically ill patients: a multicenter prospective study.

BACKGROUND: Intra-abdominal candidiasis (IAC) is difficult to predict in critically ill patients with intra-abdominal infection, leading to the overuse of antifungal treatments. Serum and peritoneal 1.3-beta-D-glucan (sBDG and pBDG) have been proposed to confirm or invalidate the diagnosis of IAC, but clinical studies have reported inconsistent results, notably because of heterogeneous populations with a low IAC prevalence. This study aimed to identify a high-risk IAC population and evaluate pBDG and sBDG in diagnosing IAC. METHODS: This prospective multicenter noninterventional French study included consecutive critically ill patients undergoing abdominal surgery for abdominal sepsis. The primary objective was to establish the IAC prevalence. The secondary objective was to explore whether sBDG and pBDG could be used to diagnose IAC. Wako® beta-glucan test (WT, Fujifilm Wako Chemicals Europe, Neuss, Germany) was used for pBDG measurements. WT and Fungitell® beta-D-glucan assay (FA, Associate of Cape Cod, East Falmouth, USA) were used for sBDG measurements. RESULTS: Between 1 January 2020 and 31 December 2022, 199 patients were included. Patients were predominantly male (63%), with a median age of 66 [54-72] years. The IAC prevalence was 44% (87/199). The main IAC type was secondary peritonitis. Septic shock occurred in 63% of cases. After multivariate analysis, a nosocomial origin was associated with more IAC cases (P = 0.0399). The median pBDG level was significantly elevated in IAC (448 [107.5-1578.0] pg/ml) compared to non-IAC patients (133 [16.0-831.0] pg/ml), P = 0.0021. For a pBDG threshold of 45 pg/ml, the negative predictive value in assessing IAC was 82.3%. The median sBDG level with WT (n = 42) at day 1 was higher in IAC (5 [3.0-9.0] pg/ml) than in non-IAC patients (3 [3.0-3.0] pg/ml), P = 0.012. Similarly, median sBDG level with FA (n = 140) at day 1 was higher in IAC (104 [38.0-211.0] pg/ml) than in non-IAC patients (50 [23.0-141.0] pg/ml), P = 0.009. Combining a peritonitis score < 3, sBDG < 3.3 pg/ml (WT) and pBDG < 45 pg/ml (WT) yielded a negative predictive value of 100%. CONCLUSION: In critically ill patients with intra-abdominal infection requiring surgery, the IAC prevalence was 44%. Combining low sBDG and pBDG with a low peritonitis score effectively excluded IAC and could limit unnecessary antifungal agent exposure. TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov (ID number 03997929, first registered on June 24, 2019).

Application of metagenomic sequencing of drainage fluid in rapid and accurate diagnosis of postoperative intra-abdominal infection: a diagnostic study.

BACKGROUND: Postoperative intra-abdominal infection (PIAI) is one of the most serious complications of abdominal surgery, increasing the risk of postoperative morbidity and mortality and prolonging hospital stay. Rapid diagnosis of PIAI is of great clinical value. Unfortunately, the current diagnostic methods of PIAI are not fast and accurate enough. METHODS: The authors performed an exploratory study to establish a rapid and accurate diagnostic method of PIAI. The authors explored the turnaround time and accuracy of metagenomic next-generation sequencing (mNGS) in diagnosing PIAI. Patients who underwent elective abdominal surgery and routine abdominal drainage with suspected PIAI were enroled in the study. The fresh midstream abdominal drainage fluid was collected for mNGS and culturing. RESULTS: The authors found that the median sample-to-answer turnaround time of mNGS was dramatically decreased than that of culture-based methods (<24 h vs. 59.5-111 h). The detection coverage of mNGS was much broader than culture-based methods. The authors found 26 species from 15 genera could only be detected by mNGS. The accuracy of mNGS was not inferior to culture-based methods in the 8 most common pathogens detected from abdominal drainage fluid (sensitivity ranged from 75 to 100%, specificity ranged from 83.3 to 100%, and kappa values were higher than 0.5). Moreover, the composition of the microbial spectrum established by mNGS varied between upper and lower gastrointestinal surgery, enhancing the understanding of PIAI pathogenesis. CONCLUSION: This study preliminarily revealed the clinical value of mNGS in the rapid diagnosis of PIAI and provided a rationale for further research.

Prolonged Therapy Is Not Associated with Delayed Identification of Recurrent Intra-Abdominal Infection.

Background: The Study to Optimize Peritoneal Infection Therapy (STOP-IT) Trial identified an association between prolonged antibiotic therapy and delayed identification of recurrent intra-abdominal infection (IAI). However, this association has not been observed in other studies. The purpose of this study was to evaluate the association between recurrent IAIs and the duration of antibiotic agents. Patients and Methods: Adult patients from 2016 to 2020 who underwent a source control procedure for a colon-related complicated IAI were identified. Patients not meeting the inclusion criteria were excluded. Demographics, comorbidities, post-operative antibiotic duration, and presence of secondary intra-abdominal infection were recorded. The primary outcome was the time to identification of secondary IAI. Delayed identification of recurrent infection was identified as 10 or more days following source control procedure. Statistical analysis using χ2, Fisher exact, and Wilcoxon rank sum were used where appropriate. Results: Seventy-six of the patients identified met inclusion criteria, and 17 (22.4%) of those patients had a recurrent IAI. Patients with recurrent infections were slightly younger (64 vs. 60 years; p = 0.01) and had lower rates of pre-operative anticoagulation (50.8% vs. 17.6%). There were no differences in the initial length of antibiotic therapy after source control between the recurrent infection and non-recurrent groups (p = 0.6). There was a difference in total days of antibiotic use between the two groups, with the recurrent infection group averaging 10 more days of antibiotic use than the non-recurrence group (p < 0.0001). In those patients with a recurrence, there were no differences in median days to identification (9 vs. 11.5 days; p = 0.29) or the rate of those with delayed identification of recurrent infection (44.4% vs. 75%; p = 0.33). Conclusions: Similar to the STOP-IT Trial we failed to identify an association between the duration of post-operative antibiotic agents and recurrent infection. However, we further failed to identify an association between the prolonged post-operative courses and the timing of identification of the recurrent infection. Further evaluation is needed to determine if prolonged therapy delays the identification of recurrent infection.

Predictive Role of Changes in Presepsin and Early Sepsis in ICU Patients After Abdominal Surgery.

INTRODUCTION: It is difficult to identify early sepsis after surgery due to postoperative inflammatory reactions. Presepsin, a glycoprotein expressed on the surface of innate immune cells, is produced during bacterial phagocytosis, and its level increases in the bloodstream of sepsis patients. We aimed to measure the differences between the diagnostic ability of presepsin and other biomarkers to identify postoperative sepsis and septic shock in acute period after major abdominal surgery. METHODS: From March 2020 to March 2021, patients who underwent surgery due to intra-abdominal infection were enrolled. Level of presepsin and procalcitonin, and white blood cell counts were prospectively measured every morning for 3 d from intensive care unit admission after surgery (from T0 to T3). Diagnostic values of inflammatory markers were compared to predict early development of sepsis or septic shock within 7 d after surgery. Cut-off value of significant risk factor associated with postoperative sepsis or septic shock were evaluated. RESULTS: Among 298 patients, postoperative sepsis and septic shock occurred in 91 and 38 patients, respectively. For prediction of early postoperative sepsis or septic shock, presepsin and procalcitonin had comparable diagnostic abilities. In multivariate analysis, presepsin > 406.5 pg/mL at T0 (Odds Ratio [OR]:4.055, P = 0.047), presepsin > 1216 pg/mL at T2 (OR:40.030, P = 0.005) and procalcitonin > 1.685 ng/mL at T2 (OR: 5.229, P = 0.008) were significant factors for predicting the occurrence of early postoperative septic shock. CONCLUSIONS: Diagnostic accuracy of presepsin for sepsis or septic shock was feasible in acute postoperative period. It would be useful to monitor newly developed sepsis from normal inflammatory response, especially in patients who underwent surgical operation for the elimination of intra-abdominal infection.

Time to source control and outcome in community-acquired intra-abdominal infections: The multicentre observational PERICOM study.

BACKGROUND: Optimal management of community-acquired intra-abdominal infections (IAI) requires timely surgical source control and adequate anti-infective treatment. OBJECTIVE: To describe the initial management of community-acquired IAI admitted to the emergency department and assess the association between the length of time to either diagnosis or therapeutic procedures and patient outcomes. DESIGN: A prospective, multicentre, observational study. SETTING: Thirteen teaching hospitals in France between April 2018 and February 2019. PATIENTS: Two hundred and five patients aged at least 18 years diagnosed with community-acquired IAI. MAIN OUTCOME MEASURES: The primary outcome was hospital length of stay. The secondary outcome was hospital mortality. RESULTS: Patients had a mean age of 56 (± 21) years and a median [interquartile] SAPS II of 26 [17 to 34]. Among the study cohort, 18% were postoperatively transferred to intensive care unit and 7% had died by day 28. Median [IQR] time to imaging, antibiotic therapy and surgery were 4 [2 to 6], 7.5 [4 to 12.5] and 9 [5.5 to 17] hours, respectively. The length of time to surgical source control [0.99, 95% confidence interval (CI), 0.98 to 0.99], SOFA greater than 2 [0.36 (95% CI, 0.26 to 0.651)], age greater than 60 years [0.65 (95% CI, 0.45 to 0.94)], generalized peritonitis [0.7 (95% CI, 0.56 to 0.89)] and laparotomy surgery [0.657 (95% CI, 0.42 to 0.78)] were associated with longer hospital length of stay. The duration of time to surgical source control [1.02 (95% CI, 1.01 to 1.04)], generalized peritonitis [2.41 (95% CI, 1.27 to 4.61)], and SOFA score greater than 2 [6.14 (95% CI, 1.40 to 26.88)] were identified as independent risk factors for 28-day mortality. CONCLUSION: This multicentre observational study revealed that the time to surgical source control, patient severity and generalized peritonitis were identified as independent risk factors for increased hospital LOS and mortality in community-acquired IAI. Organisational strategies to reduce the time to surgical management of intra-abdominal infections should be further evaluated. STUDY REGISTRATION: ClinicalTrials.gov on 1 April 2018, NCT03544203.

Clinical and microbiological characteristics of polymicrobial bacteremia: a retrospective, multicenter study.

PURPOSE: To clarify the clinical and microbial characteristics of polymicrobial bacteremia (PMB) to contribute to improvements in clinical diagnosis and effective early treatment. METHODS: This retrospective multicenter study used data from three acute-care hospitals in Okayama Prefecture, Japan, collected between January 2014 and March 2019. We reviewed the demographics, comorbidities, organisms isolated, infectious focus, and 30-day mortality of patients with PMB. RESULTS: Of the 7233 positive blood cultures, 808 (11.2%) were positive for more than one organism. Of the patients with bacteremia, 507 (7.0%) had PMB, of whom 65.3% were male. Infectious foci were identified in 78.3% of the cases, of which intra-abdominal infections accounted for 47.1%. A combination of Gram-positive cocci (GPC) (chain form) and Gram-negative rods (GNR) accounted for 32.9% of the cases, and GPC/GNR and GNR/GNR patterns were significantly associated with intra-abdominal infections. The 30-day mortality rate of patients with PMB was 18.1%, with a median of 7.5 days from diagnosis to death. The mortality in patients with an infectious focus identified was significantly lower than that in patients with an unknown focus (16.3% vs. 24.5%; p = 0.031). CONCLUSIONS: Intra-abdominal infections were the most common source of PMB, and were strongly associated with a Gram-staining combination pattern of GPC (chain form)/GNR. PMB cases with an unknown focus had a poorer prognosis, highlighting the importance of early diagnosis and appropriate treatment.

Significance of Biomarkers in Early Diagnosis of Abdominal Sepsis.

INTRODUCTION/OBJECTIVE: Peritonitis is one of the most important sources of abdominal sepsis. Since intra-abdominal infection leads to the activation of the inflammatory response, this suggested that some of these mediators could be used as markers of the severity of newly formed sepsis, but primarily to identify or rule out new-onset sepsis. The aim of this study was to evaluate the sensitivity and specificity of serum markers of inflammation: C-reactive protein, procalcitonin and serum amyloid A in the serum of patients with diffuse secondary peritonitis. Methods: The prospective cohort study was conducted at the Clinic for Emergency Surgery of the Clinical Center of Serbia in Belgrade. The study group consisted of 100 patients aged 18 to 70 years, with signs of acute abdomen due to diffuse secondary peritonitis. Results: CRP and PCT are so far among the most valuable preoperative markers for distinguishing sepsis from SIRS. On the first postoperative day the analysis of the relationship between sensitivity and specificity at the different breakpoints used indicates a greater diagnostic accuracy and greater sensitivity of SAA compared to CRP and PCT. In the remaining postoperative period in our study, the ROC curve mostly coincided with the diagonal line, so CRP, PCT, and SAA had little diagnostic accuracy. CONCLUSION: The results of our study suggest that finding a specific marker for the diagnosis of abdominal sepsis, a marker that would differentiate between SIRS and sepsis, pre- and postoperatively, would be very useful.

Intra-abdominal Infections.

Intra-abdominal infections (IAIs) are a common cause of sepsis, and frequently occur in intensive care unit (ICU) patients. IAIs include many diagnoses, including peritonitis, cholangitis, diverticulitis, pancreatitis, abdominal abscess, intestinal perforation, abdominal trauma, and pelvic inflammatory disease. IAIs are the second most common cause of infectious morbidity and mortality in the ICU after pneumonia. IAIs are also the second most common cause of sepsis in critically ill patients, and affect approximately 5% of ICU patients. Mortality with IAI in ICU patients ranges from 5 to 50%, with the wide variability related to the specific IAI present, associated patient comorbidities, severity of illness, and organ dysfunction and failures. It is important to have a comprehensive understanding of IAIs as potential causes of life-threatening infections in ICU patients to provide the best diagnostic and therapeutic care for optimal patient outcomes in the ICU.

Procalcitonin and C-Reactive Protein as an Early Predictor of Infection in Elective Gastrointestinal Cancer Surgery-a Prospective Observational Study.

BACKGROUND: Postoperative infections are a common entity following elective gastrointestinal surgery among which intra-abdominal infection is notorious and life threatening. Early detection could reduce postoperative morbidity and permit safe and early discharge. This study was aimed to establish the usefulness of procalcitonin (PCT) and C-reactive protein (CRP) on postoperative day 3 as reliable markers for early detection of intra-abdominal infection and other postoperative infections following elective gastrointestinal cancer surgery. METHODS: A total of 125 patients following elective gastrointestinal cancer surgery were prospectively observed until discharge from January 2018 to December 2019. The incidence of intra-abdominal infections and other postoperative infections was recorded. Serum PCT and CRP were estimated on postoperative day 3 for all the patients. ROC analysis of PCT and CRP was performed to establish their predictability in detecting these infections. Risk factors for postoperative infections were also studied. RESULTS: The incidence of intra-abdominal infection (IAI) was 24%. The difference in PCT between the infected and non-infected patients was statistically significant (p = 0.001) but not in CRP (p = 0.223). On ROC analysis of CRP and PCT in detecting IAI, the areas under the curve were 0.494 and 0.615 respectively. CONCLUSION: Raised serum PCT values on postoperative day 3 indicate the presence of infections and should prompt the surgeon to consider other investigations to confirm the presence of IAI and other postoperative infections and plan early intervention thus expediting the postoperative recovery. CLINICAL TRIAL REGISTRATION NUMBER: CTRI/2018/12/016695.

Peritonitis terciaria como reto para los cuidados intensivos / Tertiary Peritonitis as a Challenge for Intensive Care

Introducción: Las infecciones intrabdominales son consideradas como una de las primeras causas de emergencias quirúrgicas a nivel mundial. El reconocimiento de la peritonitis terciaria como una nueva forma de sepsis de origen intrabdominal y disfunción- falla multiorgánica es creciente, pero no unánime. Objetivo: Realizar un análisis de la literatura sobre la peritonitis terciaria, su definición, elementos fisiopatológicos, factores de riesgo y terapéutica. Método: Se realizó una búsqueda en las bases de datos Pubmed, LILACS, SciELO y Google académico. Se utilizaron palabras clave, términos DeCs y MESH, en el periodo de búsqueda 2010-2020 en idioma inglés y español, con el fin de proporcionar los conceptos, clasificaciones y manejo integral en el abordaje de la peritonitis terciaria. Los tipos de estudios seleccionados fueron guías, revisiones sistemáticas, ensayos clínicos aleatorizados y estudios observacionales. Desarrollo: Se definió como una inflamación peritoneal que persistió o recurrió después de 48 horas, con signos clínicos de irritación peritoneal, tras un tratamiento aparentemente adecuado que siguió a una peritonitis secundaria y producida por patógenos nosocomiales. Es una entidad que tuvo una elevada mortalidad, que cuenta con elementos necesarios para su diagnóstico, con una flora bacteriana característica, generalmente microorganismos de baja virulencia unido a predisposición por paciente inmunocomprometido y los elementos claves para su tratamiento son la antibiótico terapia y un manejo quirúrgico adecuado. Conclusiones: A pesar de la gravedad extrema de esta entidad, existen ambigüedades en su definición, diagnóstico y tratamiento. Los estudios sobre el tema abordan definiciones muy heterogéneas y por tanto los resultados son muy variables(AU)

Introduction: Intraabdominal infections are considered one of the leading causes of surgical emergencies worldwide. Recognition of tertiary peritonitis as a new form of sepsis of intraabdominal origin and multi-organ dysfunction and/or failure is increasing, but not unanimous. Objective: To carry out an analysis of the literature about tertiary peritonitis, its definition, pathophysiological elements, risk factors, and therapy. Method: A search was carried out in the databases of Pubmed, LILACS, SciELO and Google Scholar. Keywords, as well as DeCs and MESH terms were used in the search period 2010-2020, in English and Spanish, in order to provide the concepts, classifications and the comprehensive management for tertiary peritonitis. The types of studies selected were guidelines, systematic reviews, randomized clinical trials, and observational studies. Development: The condition was defined as a peritoneal inflammation that persisted or recurred after 48 hours, with clinical signs of peritoneal irritation, after apparently adequate treatment that followed secondary peritonitis caused by nosocomial pathogens. The entity had a high mortality, with necessary elements for its diagnosis: a characteristic bacterial flora, generally low virulence microorganisms and predisposition to affect immunocompromised patients. The key elements for its treatment are antibiotic therapy and suitable surgical management. Conclusions: Despite the extreme severity of this entity, there are ambiguities in its definition, diagnosis and managment. Studies on the subject address very heterogeneous definitions and, therefore, the outcomes are highly variable(AU)

Three cases of Sutterella wadsworthensis bacteremia secondary to abdominal infections.

The anaerobic bacterium Sutterella wadsworthensis has previously been isolated from the human intestine, both in healthy individuals and patients with gastrointestinal disorders, and the clinical significance of this bacterium is unknown. In this case report, we describe three cases of bacteremia with Sutterella wadsworthensis, from patients with recent intraabdominal surgery.

[Value of procalcitonin and critical illness score in etiological diagnosis and prognosis of sepsis caused by intra-abdominal infections].

OBJECTIVE: To compare the early and late predictive values of critical illness score (CIS) and procalcitonin (PCT) in septic patients with blood stream infection (BSI) induced by intra-abdominal infection (IAI), and to identify the value of PCT in etiological diagnosis. METHODS: The clinical data of patients with at least one positive blood culture within 24 hours admission to the emergency department of China-Japan Friendship Hospital from January 2014 to December 2019 and with final diagnosis of IAI induced sepsis were enrolled. Sequential organ failure assessment (SOFA), mortality in emergency department sepsis (MEDS), Logistic organ dysfunction system (LODS), and acute physiology and chronic health evaluation II (APACHE II) scores were calculated based on the parameters on the day of admission. Differences in various indicators among different Gram-stained bacterial infections and among patients with different prognosis at 28 days or 60 days were compared. Receiver operator characteristic curve (ROC curve) was used to analyze the value of PCT in differential etiological diagnosis of IAI induced sepsis caused by single bacterial infection, and the predictive value of CIS and PCT on 28-day and 60-day death of septic patients with BSI induced by IAI. RESULTS: A total of 221 septic patients with IAI caused by single bacterial infection were enrolled. The 28-day mortality was 19.9% (44/221), and the 60-day mortality was 25.8% (57/221). Mortality caused by Gram-positive (G+) bacterial infection of patients was significantly higher than that caused by Gram-negative (G-) bacterial infection (28 days: 34.6% vs. 11.4%, 60 days: 42.0% vs. 16.4%, both P < 0.01). Compared with patients with G+ bacterial infection, the PCT value of patients with G- bacterial infection was higher [µg/L: 4.31 (0.71, 25.71) vs. 1.29 (0.32, 10.83), P < 0.05]. Compared with survival group, the values of CIS and PCT in death group were higher, either in 28 days or in 60 days [death group vs. survival group in 28 days: SOFA score was 6.0 (4.0, 10.0) vs. 3.0 (2.0, 5.0), MEDS score: 11 (9, 14) vs. 6 (6, 9), LODS score: 4.0 (2.0, 6.0) vs. 1.0 (0, 2.0), APACHE II score: 17.0 (15.0, 24.0) vs. 12.0 (8.0, 15.0), PCT (µg/L): 3.48 (1.01, 26.70) vs. 2.45 (0.32, 15.65); death group vs. survival group in 60 days: SOFA score: 6.0 (4.0, 10.0) vs. 3.0 (2.0, 5.0), MEDS score: 9 (6, 14) vs. 6 (6, 9), LODS score: 4.0 (1.0, 5.0) vs. 1.0 (0, 2.0), APACHE II score: 16.5 (12.0, 20.0) vs. 12.0 (8.0, 15.0), PCT (µg/L): 2.67 (0.98, 17.73) vs. 2.22 (0.31, 16.75); all P < 0.05]. ROC curve showed that: (1) the area under ROC curve (AUC) of PCT in the diagnosis of IAI induced sepsis with single bacterial infection was 0.740 [95% confidence interval (95%CI) was 0.648-0.833]. When the optimal cut-off value of PCT was 1.82 µg/L, the sensitivity of diagnosis of G- bacterial infection was 74.0%, and the specificity was 68.2%. When PCT value was higher than 10.92 µg/L, the specificity of diagnosis of G- bacterial infection could reach 81.8%. (2) In the prediction of 28-day and 60-day mortality for septic patients with BSI induced by IAI, the APACHE II score achieved the highest AUC [28 days: 0.791 (95%CI was 0.680-0.902), 60 days: 0.748 (95%CI was 0.645-0.851)]. APACHE II score higher than 14.5 could help to predict 28-day and 60-day mortality for IAI patients with negative predictive values of 94.9% and 88.5%. However, the predictive value of PCT for septic patients with BSI induced by IAI was relatively lower [28-day AUC: 0.610 (95%CI was 0.495-0.725), 60-day AUC: 0.558 (95%CI was 0.450-0.667)]. CONCLUSIONS: PCT is more reliable in the identification of pathogen type among IAI induced sepsis with BSI, while APACHE II score may perform better in predicting early and late mortality.

A probabilistic model for the prediction of intra-abdominal infection after colorectal surgery.

AIM: Predicting intra-abdominal infections (IAI) after colorectal surgery by means of clinical signs is challenging. A naïve logistic regression modeling approach has some limitations, for which reason we study two potential alternatives: the use of Bayesian networks, and that of logistic regression model. METHODS: Data from patients that had undergone colorectal procedures between 2010 and 2017 were used. The dataset was split into two subsets: (i) that for training the models and (ii) that for testing them. The predictive ability of the models proposed was tested (i) by comparing the ROC curves from days 1 and 3 with all the subjects in the test set and (ii) by studying the evolution of the abovementioned predictive ability from day 1 to day 5. RESULTS: In day 3, the predictive ability of the logistic regression model achieved an AUC of 0.812, 95% CI = (0.746, 0.877), whereas that of the Bayesian network was 0.768, 95% CI = (0.695, 0.840), with a p-value for their comparison of 0.097. The ability of the Bayesian network model to predict IAI does present significant difference in predictive ability from days 3 to 5: AUC(Day 3) = 0.761, 95% CI = (0.680, 0.841) and AUC(Day 5) = 0.837, 95% CI = (0.769, 0.904), with a p-value for their comparison of 0.006. CONCLUSIONS: Whereas at postoperative day 3, a logistic regression model with imputed data should be used to predict IAI; at day 5, when the predictive ability is almost identical, the Bayesian network model should be used.