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PubMed1994

Intraabdominal infection: differences in presentation and outcome between younger patients and the elderly.

Although the elderly account for a disproportionate number of patients with intraabdominal infections, few studies have compared these patients with younger patients in terms of presentation and outcome. Therefore, we conducted a retrospective cohort study of 131 patients at an urban university hospital that included 88 patients (67%) < or = 65 years of age and 43 (33%) > 65 years of age, all of whom had culture-proven intraabdominal infections. Geriatric patients presented more frequently without the typical symptoms and signs of abdominal pain, nausea and vomiting, diarrhea, and fever and had symptoms for a longer period before presentation. Diagnosis on admission was more often unknown or considered to be of an extraabdominal nature for the elderly patients, and sources of infection were more commonly biliary or pancreatic. Mortality was not significantly different between the groups, but length of stay and duration until normalization of body temperature were longer for the older patients. We concluded that elderly patients with intraabdominal infections frequently present atypically and have a more-protracted course of illness than their younger counterparts.

Abdominal Abscess↗

PubMed2000

Reconstructive intestinal surgery after open management of severe intraabdominal infection.

Open management (OM) of severe intraabdominal infection often is complicated by fistula formation and the need for complex reconstructive procedures. From 1988 to 1998 a series of 145 patients were treated by OM. Of these patients, 24 developed intestinal fistulas and 42 had to be treated by discontinuity resections prior to OM for intestinal perforations or anastomotic insufficiency. Of the patients with fistulas or enterostomies, 61% survived. Reconstructive surgery was performed after infections had completely subsided. Patients were examined on follow-up, and the quality of life was assessed by 36-item short-form health survey questionnaires. Restorative surgery was performed in 32 of 40 patients 102 days (median) after beginning OM. All patients survived. Anastomotic leakage developed in six patients (18%). Thirty patients (94%) were followed up; 70% indicated their quality of life to be good. Despite a higher rate of anastomotic problems than with elective visceral operations, reconstructive intestinal surgery after OM may be performed without mortality and satisfying long-term outcome.

Abdominal Abscess↗

PubMedDate not supplied

Imipenem/cilastatin in the treatment of intraabdominal infections: a review of worldwide experience.

Imipenem is a new broad-spectrum beta-lactam antibiotic, which when administered with cilastatin may be a suitable alternative to the combination of an aminoglycoside and either clindamycin or a nitroimidazole as therapy for intraabdominal infections. The clinical and microbiologic results for 164 assessable patients given imipenem/cilastatin for intraabdominal infections are reported. Only three of 416 bacterial strains isolated prior to therapy from intraabdominal infection sites were resistant to imipenem (one of Staphylococcus epidermidis, one of Morganella morganii, and one of the Fusobacterium varium). Resistance acquired during treatment was reported in four cases: for three strains of Pseudomonas aeruginosa and for one strain of Proteus mirabilis. Of 412 strains susceptible to imipenem prior to therapy, 359 were eradicated during treatment. The frequency of clinical cure or improvement was 91%. Imipenem/cilastatin seems to be a useful alternative to the combination of an aminoglycoside with either clindamycin or a nitroimidazole.

Abdomen↗

PubMedDate not supplied

Treatment of intraabdominal infection with moxalactam.

Forty-eight case report forms for patients with cultures positive for intraabdominal infection treated with moxalactam were reviewed. The infections included abscess or peritonitis due to appendicitis (26); intraabdominal abscess of other causes (7); peritonitis due to bowel perforation (6), bowel infarction (5), or salpingitis (3); and gangrenous cholecystitis (1). Cultures of peritoneal fluid or abscess contents were performed for all patients. Seventy-eight aerobes and 118 anaerobes were isolated from the 48 patients. Thirty-eight patients (79.2%) were cured, therapy failed in nine (18.8%), and one (2%) developed fatal superinfection with Candida. The nine patients for whom treatment failed had a higher frequency of resistant anaerobes in their initial cultures (59%) than did the patients who were cured (29%; P = 0.036). An enterococcal isolate appeared to play a role in at least one treatment failure. There were no serious adverse reactions; eosinophilia (greater than 500 eosinophils/mm3) occurred in 17.4% of the patients, and phlebitis at the intravenous administration site occurred in one patient. Thus moxalactam shows promise as a single agent for the treatment of intraabdominal infections.

Abdomen↗

PubMedDate not supplied

The role of anaerobic bacteria in intraabdominal infections.

The exact role the anaerobic enteric flora plays in the pathogenesis and persistence of intraabdominal infections due to perforation of a hollow viscus is still unclear. Four lines of evidence have been evaluated. (1) Careful cultures of intraabdominal infections almost always yield anaerobic bacteria, but only relatively few species are predictably found, compared with the hundreds of species populating the colon. (2) Experimental models have demonstrated that the pathogenetic roles of aerobes and anaerobes differ from one another during the establishment of mixed intraabdominal sepsis. Facultative organisms induce more systemic toxicity, and anaerobes predispose to abscess formation. Evidence is inconclusive whether true synergy between aerobes and anaerobes exists in such models. (3) Studies of oral prophylactic antibiotics strongly support the important role of the anaerobic component of colonic contents in the pathogenesis of postoperative infections. (4) Studies using therapeutic antibiotics generally favor coverage for both aerobic and anaerobic components of the contaminating enteric contents. Properly performed clinical studies directed at this latter point, however, are disappointingly few.

Animals↗

PubMed1993

Infected intraabdominal hematomas: percutaneous drainage.

Percutaneous drainage of infected intraabdominal hematomas has often been contraindicated due to its greater number of complications. The results of percutaneous drainage of infected localized hematomas in five cases are described, two in the lesser sac and three in the right subphrenic space. The catheter size ranged from 8.4 to 24 French. Mean maintenance time of the drainage was 37 days. Drainage tube obstruction occurred in three patients, in two of whom the drainage tube had to be changed for one with a broader gauge. Hematomas were completely resolved in all the cases. We describe our experience with one patient in whom we used intracavitary urokinase who showed successful results. Percutaneous drainage is not contraindicated in the management of infected hematomas, although the drainage tube must be closely controlled; drainage time may be longer than in other types of abscesses.

Abdomen↗

PubMed1988

The spectrum of Escherichia coli--Bacteroides fragilis pathogenic synergy in an intraabdominal infection model.

Pathogenic synergy between Escherichia coli and Bacteroides fragilis was investigated in an intraabdominal infection model. Defined inocula of E. coli and B. fragilis, alone or in combination, were enmeshed within a fibrin clot and surgically implanted into the peritoneal cavity of rats. A spectrum of bacterial synergy ranging from synergistic abscess formation to synergistic lethality was demonstrated using this model. The type of synergy exhibited was dependent upon the initial E. coli inoculum. When combined with B. fragilis, high inocula of E. coli (greater than 10(8) cfu/clot) produced synergistic lethality while low inocula (2 x 10(2) to 2 x 10(7) cfu/clot) resulted in synergistic abscess formation. With respect to abscess formation, there was reciprocal synergy between E. coli and B. fragilis. Abscesses resulting from mixed inocula were larger and had significantly higher numbers of E. coli and B. fragilis than abscesses initiated by monomicrobial inocula. These studies define a clinically relevant model of bacterial interactions in the setting of intraabdominal infection and suggest that conclusions drawn from experimental models of bacterial synergy should consider the type of model examined, the strains of bacteria studied, and the number of bacteria inoculated.

Abscess↗

PubMed2001

Tertiary peritonitis (recurrent diffuse or localized disease) is not an independent predictor of mortality in surgical patients with intraabdominal infection.

BACKGROUND: It is well documented that tertiary peritonitis is associated with different microbiological flora and worse outcomes than secondary peritonitis. It is unknown, however, if these differences can be explained simply by the nosocomial nature of tertiary peritonitis and underlying severity of illness. METHODS: We reviewed all episodes of intraabdominal infection on the inpatient surgical services at a university hospital over a 46-month period. Univariate analysis and logistic regression were used to compare 91 episodes of secondary peritonitis that progressed to tertiary peritonitis (recurrent diffuse or localized intraabdominal infection) to all episodes of secondary peritonitis (n = 453) to identify predictors for developing tertiary peritonitis. Logistic regression was also used to identify predictors of mortality among patients with secondary (n = 473) or tertiary peritonitis (n = 129). RESULTS: Of 602 episodes of intraabdominal infection identified, there were 473 episodes of secondary peritonitis, including 20 patients who died within seven days of diagnosis. A total of 129 episodes of tertiary peritonitis were identified, of which 91 were preceded by a single episode of secondary peritonitis, and 38 were preceded by an episode of secondary peritonitis and at least one prior episode of tertiary peritonitis. Tertiary peritonitis was associated with a high APACHE II score (14.9 +/- 0.7), pancreatic or small bowel source, drainage only at initial intervention, gram-positive and fungal pathogens, and a high mortality rate (19%). Increasing APACHE II score (OR 1.07, 95% CI 1.03-1.16, p = 0.0009) independently predicted progression from secondary to tertiary peritonitis while increasing age (OR 0.98, 95% CI 0.97-0.99, p = 0.01) and appendiceal source (OR 0.12, 95% CI 0.02-0.68, p = 0.02) predicted non-progression to tertiary peritonitis. Independent predictors of mortality in this population included increasing age (OR 1.06, 95% CI 1.03-1.1, p < 0.001), increasing APACHE II score (OR 1.18, 95% CI 1.11-1.3, p < 0.001), and four comorbidities: cerebrovascular disease (OR 4.3, 95% CI 1.4-13.1, p = 0.01), malignant disease (OR 2.9, 95% CI 1.3-6.5, p = 0.01), hemodialysis dependency (OR 3.8, 95% CI 1.3-11.2, p = 0.02), and liver disease (OR 4.2, 95% CI 1.6-15.1, p = 0.03). Tertiary peritonitis was not an independent predictor of mortality. CONCLUSIONS: We were unable to demonstrate, when compared to secondary peritonitis, that tertiary peritonitis is a significant independent predictor of mortality when other variables are taken into account. This suggests that the high mortality associated with tertiary peritonitis is more a function of the patient population in which it occurs than the severity of the pathologic process itself.

APACHE↗

PubMedDate not supplied

Operative management of intraabdominal infection.

Surgical principles in the management of intraabdominal infection have remained constant. Rather, it is the application of these principles in selected cases that has varied. Judgement, therefore, becomes paramount for the surgeon. In selected cases multiple planned relaparotomies may be the most effective means of closing the infectious source and eliminating toxic infectious materials. The Burr has proven to be an effective yet safe means of permitting entry and closure of the abdominal fascia.

Abdomen↗

PubMed1984

Intraabdominal infection: diagnosis and treatment in the elderly patient.

Intraabdominal infections in the elderly are major diagnostic and therapeutic problems encountered by clinicians. Biliary sepsis, diverticulitis, appendicitis, and intraabdominal abscess cause significant morbidity and mortality in the geriatric patient. The clinical manifestations, diagnostic approach, and treatment of these infections are formulated in this review.

Abscess↗

PubMed1995

[Studies of liver macrophage function in the intraabdominal infection after partial hepatectomy in the rat model].

The activities of superoxide (O2-), tumor necrosis factor (TNF) and interleukin-1 (IL-1) of rat liver macrophage (M phi) were studied in the condition of intraabdominal infection (E group), hepatectomy (H group) and intraabdominal infection following hepatectomy (HE group). In the early stage of E and HE groups, O2- production was significantly increased after infection. In the H and HE groups, O2- production was significantly increased at 48 hours after hepatectomy, probably due to liver regeneration. In every group, the changes of TNF activity showed the similar pattern to those of O2- production. In H and E groups, the elevation of IL-1 activities was significantly increased. However in HE group, the IL-1 level remained low during 72 hours. When the M phi 48 hours following hepatectomy was stimulated by lipopolysaccharide (LPS), activities of TNF and IL-1 were correlated and reversely correlated with the LPS level, respectively. In the excessive stimulation by infection following hepatectomy, IL-1 activity is significantly suppressed with production of O2- and TNF by M phi maintained.

Animals↗

PubMed2004

Ascites and intraabdominal infection.

PURPOSE OF REVIEW: This review will give an overview of current trends in diagnosis, treatment, and pathogenesis of ascites and intraabdominal infection in cirrhotic and noncirrhotic critically ill patients. RECENT FINDINGS: Single clone-bacterial DNA has been found in sterile ascites and serum, proving the concept of direct translocation. Activation of mesenteric macrophages can be induced by splanchnic vasodilatation but also by hypoxia. Carbon monoxide, an end product of heme catabolism, promotes splanchnic vasodilatation, representing a possible link between gastrointestinal hemorrhage and circulatory dysfunction. Colorimetric test strips and automated counters accurately diagnose spontaneous bacterial peritonitis. Vasopressin V2-antagonists have been introduced as novel therapy for impaired water excretion in hyponatremia. SUMMARY: Emerging pathophysiological concepts have modified the conventional view of hydrostatic and Starling forces in the evolution of ascites. Current data indicate that the dynamic sequence of bacterial translocation, mesenteric inflammation, splanchnic vasodilatation and intrahepatic vasoconstriction determines occurrence, severity, and outcome of ascites and intraabdominal infection.

Ascites↗

PubMed2005

Acquisition of resistant bowel flora during a double-blind randomized clinical trial of ertapenem versus piperacillin-tazobactam therapy for intraabdominal infections.

Bowel colonization with resistant bacteria can develop in patients receiving broad-spectrum antimicrobial therapy. We compared the impact of two antimicrobial regimens often used to treat intraabdominal infections on susceptibility patterns of bowel flora at the end of therapy. In a double-blind clinical trial, adults with complicated intraabdominal infection requiring surgery were randomized to receive piperacillin-tazobactam (3.375 g every 6 h) or ertapenem (1 g once a day) for 4 to 14 days. Rectal swabs were obtained at baseline and at the end of study therapy to determine the acquisition rates of Enterobacteriaceae resistant to the study drug, extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli or Klebsiella species, Pseudomonas aeruginosa resistant to imipenem or piperacillin-tazobactam, and vancomycin-resistant Enterococcus faecalis or Enterococcus faecium. Treated patients were assessable for the acquisition of resistant bacteria if appropriate specimens were obtained at both time points. Enterobacteriaceae resistant to the treatment received were acquired during study therapy by 8/122 assessable piperacillin-tazobactam recipients (6.6%) compared to 0/122 assessable ertapenem recipients (P = 0.007). Neither ESBL-producing E. coli or Klebsiella species nor P. aeruginosa resistant to piperacillin-tazobactam was isolated from patients in either treatment group. Imipenem-resistant P. aeruginosa was acquired by two of the ertapenem recipients (1.6%) versus zero of the piperacillin-tazobactam recipients (P = 0.50). Vancomycin-resistant enterococci were acquired during therapy by 8/125 assessable ertapenem recipients (6.4%) versus 2/123 assessable piperacillin-tazobactam recipients (1.6%; P = 0.10). In this study, the acquisition of resistant Enterobacteriaceae occurred significantly more often in patients treated with piperacillin-tazobactam than in those treated with ertapenem.

Abdominal Abscess↗

PubMed1990

Prospective randomized study of once-daily versus thrice-daily netilmicin regimens in patients with intraabdominal infections.

One hundred and ninety-seven patients with intraabdominal infections were enrolled in a prospective randomized multicenter study of netilmicin administered once daily (n = 98) versus thrice daily (n = 99) in combination with tinidazole administered once daily. Randomization was achieved for the infection site, clinical severity score, daily and total netilmicin dose, and duration of treatment. The mean maximum peak and trough levels of netilmicin in serum were 21.1 and 1.3 mg/l respectively for once daily treated patients, and 10.0 and 2.3 mg/l for thrice daily treated patients (p less than 0.05 for both parameters). The clinical response did not differ between patients treated once daily and those treated thrice daily. Overall rates for clinical cure, improvement and failure of therapy were 77%, 17% and 6% respectively. No significant differences were found between once daily and thrice daily regimens in the occurrence of auditory, vestibular and renal toxicity, overall rates being 5%, 1% and 10% respectively. Impairment of renal function was significantly related to higher maximum netilmicin serum trough levels during therapy, a higher clinical severity score and advanced age. It is concluded that netilmicin given once daily is as effective and safe as the multiple dose regimen. However, monitoring of aminoglycoside serum through levels is still advisable, especially in the old and severely ill patient.

Abdomen↗

PubMed1983

Intraabdominal infections in the elderly.

Biliary sepsis, appendicitis, diverticulitis, and intraabdominal abscess are intraabdominal infections that are especially relevant to the elderly population. Diagnostic delays, reluctance to perform surgery, presence of underlying disease, and postoperative complications contribute to the higher morbidity and mortality rates seen for elderly patients with these infections.

Abdomen↗

PubMedDate not supplied

Multicentered study of cefoperazone for treatment of intraabdominal infections and comparison of cefoperazone with cefamandole and clindamycin plus gentamicin for treatment of appendicitis and peritonitis.

Cefoperazone was evaluated for efficacy and safety in the treatment of known or suspected intraabdominal infections. Initially, 59 patients were enrolled in an open, noncomparative study. Of the 35 patients in whom the efficacy of treatment could be evaluated, 32 had a satisfactory clinical response. In this open study, cefoperazone eradicated 62 of 71 pathogens. The safety of the drug was evaluated in all 59 patients. Adverse reactions were seen in nine patients. In the second part of the study, 144 patients were enrolled. Fifty-seven of these patients received cefoperazone, 35 received cefamandole, and 52 received clindamycin plus gentamicin. Therapeutic efficacy could be evaluated in 20 patients who received cefoperazone, 20 who received cefamandole, and 16 who received clindamycin-gentamicin. Satisfactory clinical responses were seen in 90%, 80%, and 100% of these patients, respectively; satisfactory bacteriologic responses were seen in 100%, 95%, and 100%, respectively. A 5% incidence of adverse reactions was observed among the 57 patients who received cefoperazone; in contrast, the rate of adverse reaction to cefamandole was 11%, and that to clindamycin-gentamicin was 11.5%. No differences were seen among the patients in the three groups. Thus, cefoperazone appears to be safe and effective for the treatment of intraabdominal infections of bacterial etiology.

Abdomen↗

PubMed1995

Meropenem versus tobramycin plus clindamycin for treatment of intraabdominal infections: results of a prospective, randomized, double-blind clinical trial.

The efficacy of meropenem was compared to that of the combination of tobramycin plus clindamycin (T/C) in a multiinstitutional clinical trial of treatment for patients suffering intraabdominal infection. Among the 177 patients enrolled and randomized, 127 were clinically evaluable and 86 were microbiologically evaluable. Analysis of data on an intent-to-treat basis for all randomized patients and on the basis of a successful outcome (absence of any infection) for clinically evaluable patients failed to detect any difference in efficacy between the two treatments. Infection was cleared in 92% of meropenem- and 89% of T/C-treated clinically evaluable patients. Eradication of pathogens also was similar in the two treatment groups. Overall, adverse drug experiences were comparable between the two treatment groups, with the exception of an increase in serum creatinine level (which occurred more frequently in patients receiving T/C). Meropenem appears to be efficacious for the treatment of intraabdominal infections.

Abdomen↗

PubMed2005

Antimicrobial susceptibility of aerobic microorganisms isolated from intraabdominal infections in pediatric patients in Poland.

BACKGROUND: Growing resistance to antibiotics among both community-acquired and hospital pathogens is making the treatment of most infections increasingly difficult. Therefore, the aim of our multi-center study was to determine the antimicrobial susceptibility of the most frequent aerobic microorganisms isolated from children with intraabdominal infections. MATERIAL/METHODS: Bacterial pathogens were isolated from 256 consecutive patients treated in five large specialized hospitals in Poland from January 2001 to February 2002. Minimal inhibitory concentrations (MICs) of piperacillin, piperacillin-tazobactam, cefotaxime, ceftazidime and cefepime were determined by Etests. The production of extended spectrum beta-lactamases (ESBL) was detected by a double-disk test. RESULTS: Piperacillin-tazobactam was the most active agent against Enterobacteriaceae and Pseudomonas aeruginosa, inhibiting 92% and 78% of isolates respectively. Susceptibility of Enterobacteriaceae to cefotaxime, ceftazidime and cefepime was 73%, 73% and 87% respectively, and susceptibility of P. aeruginosa to both ceftazidime and cefepime was 76%. Extended-spectrum beta-lactamases were detected in 56% Klebsiella sp. and 11.5% E. coli, but the vast majority of these isolates remained susceptible to piperacillin-tazobactam (MIC(90) = 12 mg/L and MIC(90) = 1 mg/L, respectively). CONCLUSIONS: Piperacillin/tazobactam remains a valuable therapeutic option in Polish pediatric patients with intraabdominal infections, due to its good activity against ESbetaL-producing organisms and P. aeruginosa.

Abdomen↗