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Background Depending on the extent of surgery, coagulation status and the number of anastomoses, drains are routinely used during liver transplantation. The aim of this study was to compare different drain types with regard to abdominal complication rates. Methods All consecutive full-size orthotopic liver transplantations (LTX) performed over a 7-year period were included in this retrospective analysis. Abdominal drain groups were divided into open-circuit drains and closed-circuit drains. Data are reported as total number (%) or median (range); for all comparisons a p value

Background Secondary peritonitis requires surgical source control and adequate antimicrobial treatment. Antimicrobial regimens are usually selected according to local susceptibility data of individual pathogens against single agents, but this neglects both the polymicrobial nature of the infection and the use of combination therapy. We analysed the probability of common regimens to cover all relevant pathogens isolated in one patient (“spectrum adequacy rate”, SAR) in a real-life data set. Methods Data from 242 patients with secondary peritonitis (88 community acquired, 154 postoperative cases) treated in our IMCU/ICU were obtained retrospectively. The relative frequency of pathogens, resistance rates and the SAR were analysed using the free software R. Results Enterococci were isolated in 47.1 % of all patients, followed by Escherichia coli (42.6 %), other enterobacteriaceae (33.1 %), anaerobes (29.8 %) and Candida spp. (28.9 %). Resistance patterns were consistent with general surveillance data from our hospital. The susceptibility rates and SAR were lower in postoperative than in community acquired cases. The following regimens yielded a SAR > 95 % when enterobacteriaceae only were considered: piperacillin/tazobactam + gentamicin, cefotaxim (only for community acquired cases), cefotaxim + gentamicin, meropenem, tigecycline + gentamicin or tigecycline + ciprofloxaxin. When enterococci were also considered, all betalactam based regimens required combination with vancomycin or linezolid for a SAR > 95 %, whereas TGC based regimens were not compromised. As for Candida spp., the SAR of fluconazole was 81.9–87.5 %. Conclusions This study demonstrates a rational approach to assess the adequacy of antimicrobial regimens in secondary peritonitis, which may help to adjust local guidelines or to select candidate regimens for clinical studies.

Background Portal vein thrombosis (PVT) is a rare condition associated with serious morbidity and mortality. The objective of this study was to determine the frequency, clinical presentations, and risk factors of PVT from the set of data firstly collected among the Southeast Asian population. Methods A retrospective study was undertaken to identify patients diagnosed with thrombosis of the portal system and other abdominal veins. The hospital medical records were retrieved based on the selected ICD-10 codes. Clinical presentations were collected and risk factors determined. Results From 2000-2009, 467 hospital charts with designated ICD-10 codes of I81, I82.2, I82.3, I82.8, I82.9, or K55.0 were identified. PVT (I81) was the most common thrombosis (194 cases, 41.54%). The majority of PVT patients were males (65%), older than 40 years (75%), and presented with abdominal distension/ascites (69%), splenomegaly (54.6%), and abdominal pain (50.5%). Overall, the predominant risk factor was hepatocellular carcinoma (HCC) (52.5%), followed by liver cirrhosis without cancer (9.3%), abdominal infection/inflammation (9.3%), cholangiocarcinoma (8.2%), and abdominal intervention (7.7%). In young patients, abdominal interventions including umbilical catheterization (23.1%) and hepatectomy (7.7%) were the most frequent risks whereas in older cases, primary hepatobiliary cancer and cirrhosis (78%) were the major risks. Liver metastases from other organs were infrequently found. Chronic hepatitis B virus (HBV) infection was the main etiology associated with cirrhosis/HCC leading to PVT in this cohort. A third of the older PVT patients (age >40) had HBV and very few carried hepatitis C virus (HCV) whereas none of the young PVT patients (age Conclusion HBV is the major risk of PVT in the Southeast Asian population. Several risk factors identified in this population have rarely been described and some are remarkably different from those reported in the West. Host and environmental factors may play a causal role in the initiation and development of PVT in various ethnicities and geographic locations.

Background Severe sepsis is recognized as an inflammatory response causing organ dysfunction in patients with infection. Antimicrobial therapy is the mainstay of treatment. There is an ongoing demand for local surveillance of sepsis aetiology and monitoring of empirical treatment recommendations. The present study was established to describe the characteristics, quality of handling and outcome of patients with severe sepsis admitted to a Norwegian university hospital. Methods A one year prospective, observational study of adult community acquired case-defined severe sepsis was undertaken. Demographics, focus of infection, microbiological findings, timing and adequacy of empirical antimicrobial agents were recorded. Clinical diagnostic practice was evaluated. Differences between categorical groups were analysed with Pearson’s chi-squared test. Predictors of in-hospital mortality were identified in a multivariate stepwise backward logistic regression model. Results In total 220 patients were identified, yielding an estimated annual incidence of 0.5/1000 inhabitants. The focus of infection was established at admission in 69%. Respiratory tract infection was present in 52%, while genitourinary, soft tissue and abdominal infections each were found in 12-14%. Microbiological aetiology was identified in 61%; most prevalent were Streptococcus pneumoniae, Escherichia coli and Staphylococcus aureus. Independent predictors of in-hospital mortality were malignancy, cardiovascular disease, endocarditis, abdominal infections, undefined microbiological aetiology, delay in administration of empirical antimicrobial agents ≥ 6 hours and use of inadequate antimicrobial agents. In patients ≥ 75 years, antimicrobial therapy was less in compliance with current recommendations and more delayed. Conclusions Community acquired severe sepsis is common. Initial clinical aetiology is often revised. Compliance with recommendations for empirical antimicrobial treatment is lowest in elderly patients. Our results emphasizes that quick identification of correct source of infection, proper sampling for microbiological analyses, and fast administration of adequate antimicrobial agents are crucial points in the management of severe sepsis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Intra-abdominal infection (IAI) describes a diverse set of diseases. It is broadly defined as peritoneal inflammation in response to microorganisms, resulting in purulence in the peritoneal cavity[1]. IAI are classified as uncomplicated or complicated based on the extent of infection[2]. Uncomplicated abdominal infections involve intramural inflammation of the gastrointestinal (GI) tract without anatomic disruption. They are often simple to treat; however, when treatment is delayed or inappropriate, or the infection involves a more virulent nosocomial microbe, the risk of progression into a complicated abdominal infection becomes significant[3, 4]. Complicated abdominal infections extend beyond the source organ into the peritoneal space. They cause peritoneal inflammation, and are associated with localized or diffuse peritonitis[5]. Localized peritonitis often manifests as an abscess with tissue debris, bacteria, neutrophils, macrophages, and exudative fluid contained in a fibrous capsule. Diffuse peritonitis is categorized as primary, secondary or tertiary peritonitis. Primary peritonitis is also known as spontaneous bacterial peritonitis. It is thought to be the result of bacterial translocation across an intact gut wall[6]. These infections are commonly monomicrobial, and the infecting organism is primarily determined by patient demographics. For example, healthy young girls are most often infected by streptococcal organisms, cirrhotics by gram negative or enterococcal organisms, and peritoneal dialysis patients by Staphylococcus aureus[7, 8]. Diagnosis requires peritoneal fluid aspiration. Characteristics of infection include white blood cell count (WBC) > 500 cells/mm3, high lactate, and low glucose levels. Positive peritoneal fluid cultures are definitive, and resolution of infection is marked by peritoneal fluid with < 250 WBC/mm3[9]. Secondary peritonitis is caused by microbial contamination through a perforation, laceration, or necrotic segment of the GI tract[7]. Definitive diagnosis is based on clinical examination and history, and specific diagnoses can be confirmed by radiographic imaging[10]. If a patient is stable enough for transport, computed tomography (CT) scan with intravenous and oral contrast is the standard method of evaluating most intra-abdominal pathologies, such as appendicitis, diverticulitis, and colitis[11]. Suspected biliary pathology is the exception, and ultrasound is the preferred initial imaging modality for this spectrum of disease including acute cholecystitis, emphysematous cholecystitis, and cholangitis. Infections associated with secondary peritonitis are commonly polymicrobial and the infecting organisms are those most commonly associated with the source of contamination (see Table 1). Table 1 Expected organisms according to source Source Expected Organism Primary Peritonitis Young healthy female Streptococcus Cirrhotic Enteric gram negatives Enterococcus CAPD Staphylococcus aureus Secondary peritonitis Stomach and duodenum Streptococcus Lactobacillus Biliary E. coli, Klebsiella, Enterococcus Small Intestine E. coli, Klebsiella, Lactobacillus Streptococci Diptheroids Enterococci Distal ileum and colon Bacteroides fragilis Clostridium spp. E. coli Enterobacter spp. Klebsiella spp. Peptostreptococci Enterococci Teritiary peritonitis Enterococcus Candida Staphylococcus epidermidis Enterobacter Adapted from Weigelt JA [12]. Tertiary peritonitis represents an infection that is persistent or recurrent at least 48 hours after appropriate management of primary or secondary peritonitis. It is more common among critically ill or immunocompromised patients[12]. Because of the poor host defenses, it is also often associated with less virulent organisms, such as Enterococcus, Candida, Staphylococcus epidermidis, and Enterobacter[13]. Intra-abdominal sepsis is an IAI that results in severe sepsis or septic shock[2].

International audience; Introduction: Procalcitonin (PCT) biomarker is suggested to tailor antibiotic therapy in the medical intensive care unit (ICU) but studies in perioperative medicine are scarce. The aim of this study was to determine whether PCT reported thresholds are associated with the initial treatment response in perioperative septic shock secondary to intra-abdominal infection. Methods: This single ICU, observational study included patients with perioperative septic shocks secondary to intra-abdominal infection. Demographics, PCT at days 0, 1, 3, 5, treatment response and outcome were collected. Treatment failure included death related to the initial infection, second source control treatment or a new onset intra-abdominal infection. The primary endpoint was to assess whether PCT thresholds (0.5 ng/ml or a drop from the peak of at least 80%) predict the initial treatment response. Results: We included 101 consecutive cases. Initial treatment failed in 36 patients with a subsequent mortality of 75%. Upon admission, PCT was doubled when treatment ultimately failed (21.7 ng/ml +/- 38.7 vs. 41.7 ng/ml +/- 75.7; P = 0.04). Although 95% of the patients in whom PCT dropped down below 0.5 ng/ml responded to treatment, 50% of the patients in whom PCT remained above 0.5 ng/ml also responded successfully to treatment. Moreover, despite a PCT drop of at least 80%, 40% of patients had treatment failure. Conclusions: In perioperative intra-abdominal infections with shock, PCT decrease to 0.5 ng/ml lacked sensitivity to predict treatment response and its decrease of at least 80% from its peak failed to accurately predict treatment response. Studies in perioperative severe infections are needed before using PCT to tailor antibiotic use in this population.

There are few data related to the effects of different sources of infection on outcome. We used the Sepsis Occurrence in Acutely ill Patients (SOAP) database to investigate differences in the impact of respiratory tract and abdominal sites of infection on organ failure and survival., Comparative Study, Journal Article, Multicenter Study, Research Support, Non-U.S. Gov't, SCOPUS: ar.j, info:eu-repo/semantics/published

Abdominal infection leading to sepsis is a major cause of mortality in the ICU. The inflammatory response also alters the pulmonary immunity leading to increased risk for VAP.