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Liver diseases are a significant global cause of morbidity and mortality. Liver cirrhosis can result in severe complications such as bleeding, hepatic encephalopathy (HE), and infections. Implementing a clear strategy for intensive care unit (ICU) admission management improves patient outcomes. Hemodynamically significant esophageal/gastric variceal bleeding (E/GVB) and grade 4 HE, when accompanied by the need for renal replacement therapy (RRT), are definitive indications for ICU admission. E/GVB, spontaneous bacterial peritonitis (SBP), and infections with multidrug-resistant organisms (MDRO) require close and stringent critical assessment. Patients with severe hepatorenal syndrome (HRS) or respiratory failure have increased baseline mortality and most likely benefit from early ICU treatment. Rapid identification of sepsis in patients with liver cirrhosis is a crucial criterion for ICU admission. Prioritizing cases based on mortality risk and clinical urgency enables efficient resource utilization and optimizes patient management. In addition, "Liver Units" provide an intermediate care (IMC) level for patients with liver diseases who require close monitoring but do not need immediate intensive care., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background and Aim: Patients with liver cirrhosis often face a grave threat from infected ascites (IA). However, a well-established prognostic model for this complication has not been established in routine clinical practice. Therefore, we aimed to assess mortality risk in patients with liver cirrhosis and IA., Methods: We conducted a retrospective study across three tertiary hospitals, enrolling 534 adult patients with cirrhotic liver and IA, comprising 465 with spontaneous bacterial peritonitis (SBP), 34 with bacterascites (BA), and 35 with secondary peritonitis (SP). To determine the attributable mortality risk linked to IA, these patients were matched with 122 patients with hydropic decompensated liver cirrhosis but without IA. Clinical, laboratory, and microbiological parameters were assessed for their relation to mortality using univariable analyses and a multivariable random forest model (RFM). Least absolute shrinkage and selection operator (Lasso) regression model was used to establish an easy-to-use mortality prediction score., Results: The in-hospital mortality risk was highest for SP (39.0%), followed by SBP (26.0%) and BA (25.0%). Besides illness severity markers, microbiological parameters, such as Candida spp., were identified as the most significant indicators for mortality. The Lasso model determined 15 parameters with corresponding scores, yielding good discriminatory power (area under the receiver operating characteristics curve = 0.89). Counting from 0 to 83, scores of 20, 40, 60, and 80 corresponded to in-hospital mortalities of 3.3%, 30.8%, 85.2%, and 98.7%, respectively., Conclusion: We developed a promising mortality prediction score for IA, highlighting the importance of microbiological parameters in conjunction with illness severity for assessing patient outcomes., (© 2024 The Author(s). Journal of Gastroenterology and Hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Limited availability and side effects of opioids have led to an increased use of non-opioid analgesia in animal disease models. However, by affecting the immune-inflammatory reactions, analgesia may disrupt the resolution of the host inflammation and modulate the survival in septic animals. This study used a clinically relevant sepsis mouse model of peritoneal contamination and infection (PCI) to investigate the antinociceptive and anti-inflammatory properties of two non-opioid analgesics., Methods: Adult C57BL/6J mice were intraperitoneally injected with a human feces suspension and received either no analgesics (Non-A), Meloxicam, or Metamizole orally. The mice were monitored for pain and illness. Mortality was assessed at 7 days post-PCI. A separate group of mice was sacrificed 24 hours after infection. Blood, peritoneal lavage fluid (PLF), liver, and spleen were harvested for pathogen load quantification via qPCR, macrophage phenotyping, neutrophil infiltration/activation, and systemic/tissue cytokine release by flow cytometry., Results: Meloxicam but not Metamizole reduced the mortality of septic mice by 31% on day 7 compared to the Non-A group. Both analgesics effectively alleviated pain but did not affect illness severity, body weight, and temperature. Meloxicam quadrupled the bacterial burden in the blood and PLF. In high IL-6 responders, Meloxicam treatment was associated with reduced circulating IL-10 and IL-1β compared to the Non-A septic group. In low IL-6 responders, Meloxicam increased circulating MCP-1 levels and decreased PGE2 levels compared to Non-A septic mice. Notably, Meloxicam reduced spleen neutrophil infiltration by 20% compared to two other sepsis groups., Conclusion: Metamizole and Meloxicam effectively relieved pain and increased the animals' basal activity in the PCI sepsis model. Meloxicam prolonged survival yet triggered maladaptive responses due to its immunosuppressive features that decreased tissue bacterial clearance during sepsis. In contrast, Metamizole constitutes a safe and effective non-opioid alternative for analgesic control in the non-surgical PCI sepsis model., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Liu, Sonawane, Sommerfeld, Svensson, Figge, Bauer, Bischoff, Bauer, Osuchowski and Press.)

Background: Vasodilatation and bacterial dislocation are the main contributors to the catastrophic events in patients with decompensated liver cirrhosis (DLC)., Aim: The aim of this study was to evaluate the impacts of adding midodrine and rifaximin on morbidity, mortality, and quality of life in patients with DLC., Methods: This interventional clinical study included 100 consecutively enrolled DLC patients randomized 1 : 1 into two groups. Group A received oral midodrine (5 mg/8 h) and rifaximin (550 mg/12 h) with standard diuretic therapy, while group B received only standard diuretic therapy. Clinical and laboratory data, including the McGill Quality of Life Questionnaire, were evaluated over a 3-month treatment period., Results: In the study group, there was a significant reduction in Child-Pugh and Model for End-Stage Liver Disease scores, international normalized ratio, and mean arterial blood pressure at 2, 6, and 12 weeks (P < 0.05). Ascites, spontaneous bacterial peritonitis incidence, hematemesis, paracentesis need, and hepatic encephalopathy showed improvement after 12 weeks compared with the control group. McGill Quality of Life Questionnaire significantly improved after 6 and 12 weeks (P < 0.05). Survival rates demonstrated a noteworthy improvement (P = 0.014), substantiated by evidence in both univariate and multivariate regression analyses., Conclusion: Combined midodrine with rifaximin represents an endowment to patients with DLC with spectacular improvements in synthetic liver functions, along with improved quality of life, and survival., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The prevalence of obesity is increasing worldwide. Obesity is also increasing in the chronic kidney disease (CKD) population. There are conflicting data on complications such as mortality, peritonitis, and technique proficiency of peritoneal dialysis (PD) in underweight and obese patients according to body mass index (BMI). We aimed to present the data in our region to the literature by comparing the residual renal function (RRF), peritonitis, technique proficiency, and mortality rates of the patients we grouped according to BMI., Methods: The data of 404 patients who were started and followed up in our clinic between March 2005 and November 2021 were evaluated retrospectively. They were grouped as underweight, normal weight, overweight, and obese according to BMI. RRF, mortality, technique proficiency and peritonitis data of the groups were compared., Results: Of the 404 patients, 44 were underweight, 199 were normal weight, 110 were overweight, and 55 were obese. No difference was found between the groups in the technique survey and in the time to first peritonitis with Kaplan-Meier analysis (respectively; p = 0.610, p = 0.445). Multivariate Cox regression analysis showed that BMI did not affect mortality (HR 1.196 [95% CI 0.722-1.981] (p = 0.488))., Conclusion: In conclusion, we report that BMI has no effect on RRF, peritonitis, technique proficiency, and mortality in patients undergoing PD, and that mortality may depend on additional factors such as mean albumin, time to first peritonitis, and loss of RRF., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Listeriosis is a foodborne infection caused by Listeria monocytogenes. Three main forms of listeriosis are well characterised, but little is known about L monocytogenes-associated spontaneous bacterial peritonitis. We used data from the French national surveillance of listeriosis to perform a nationwide retrospective study., Methods: All patients with L monocytogenes isolated by culture from a peritoneal fluid sample in France between April 1, 1993, and Dec 31, 2022, were included. Individuals for whom bacterial peritonitis was not confirmed and those who also had another type of invasive listeriosis were excluded. A standardised checklist was used to collect demographic, clinical, and biological data as well as antibiotic treatment and follow-up data. The primary outcome was to determine the characteristics of L monocytogenes-associated spontaneous bacterial peritonitis. We did descriptive analyses and assessed risk factors for 1-month mortality using an exploratory multivariable Cox model analysis., Findings: Among the 8768 L monocytogenes cases reported, 208 (2%) were patients with L monocytogenes-associated spontaneous bacterial peritonitis. Mean age was 65 years (SD 13), 50 (24%) of 208 patients were female, and 158 (76%) were male (no data on race or ethnicity were available). 200 (98%) of 205 patients with L monocytogenes-associated spontaneous bacterial peritonitis with available data had immunosuppressive comorbidities, including cirrhosis (148 [74%] of 201 with available data), ongoing alcoholism (58 [62%] of 94), and ongoing neoplasia (60 [31%] of 195). Causes of ascites included cirrhosis (146 [70%] of 208), ongoing neoplasia (26 [13%]), end-stage heart failure (13 [6%]), and peritoneal dialysis (11 [5%]). Among those with available data, presentation was pauci-symptomatic and non-specific; only 67 (50%) of 135 patients presented with fever, 49 (37%) of 132 with abdominal pain, and 27 (21%) of 129 with diarrhoea. 61 (29%) of 208 patients were dead at 1 month, 92 (44%) were dead at 3 months, and 109 (52%) were dead at 6 months after diagnosis. Ongoing neoplasia (hazard ratio 2·42 [95% CI 1·05-5·56]; p=0·039), septic shock (8·03 [2·66-24·02]; p=0·0021), and high blood leukocyte count (1·05 [1·00-1·09]; p=0·045) were independently associated with 1-month mortality., Interpretation: Despite the non-specific and mild presentation of L monocytogenes-associated spontaneous bacterial peritonitis, the outcome is poor and similar to that of neurolisteriosis, and so identification of L monocytogenes in ascitic fluid samples requires urgent parenteral amoxicillin-based treatment to avoid a fatal outcome., Funding: Institut Pasteur, Inserm, and French Public Health Agency., Translation: For the French translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests We declare no competing interests., (© 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Introduction: severe abdominal sepsis, accompained by diffuse peritonitis, poses a significant challenge for most surgeons. It often requires repetitive surgical interventions, leading to complications and resulting in high morbidity and mortality rates. The open abdomen technique, facilitated by applying a negative-pressure wound therapy (NPWT), reduces the duration of the initial surgical procedure, minimizes the accumulation of secretions and inflammatory mediators in the abdominal cavity and lowers the risk of abdominal compartment syndrome and its associated complications. Another approach is primary closure of the abdominal aponeurosis, which involves suturing the layers of the abdominal wall., Methods: the objective of this study is to conduct a survival analysis comparing the treatment of severe abdominal sepsis using open abdomen technique versus primary closure after laparotomy in a public hospital in the South of Brazil. We utilized data extracted from electronic medical records to perform both descriptive and survival analysis, employing the Kaplan-Meier curve and a log-rank test., Results: the study sample encompassed 75 laparotomies conducted over a span of 5 years, with 40 cases employing NPWT and 35 cases utilizing primary closure. The overall mortality rate observed was 55%. Notably, survival rates did not exhibit statistical significance when comparing the two methods, even after stratifying the data into separate analysis groups for each technique., Conclusion: recent publications on this subject have reported some favorable outcomes associated with the open abdomen technique underscoring the pressing need for a standardized approach to managing patients with severe, complicated abdominal sepsis.

To determine if preoperative-intraoperative factors such as age, comorbidities, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), and severity of peritonitis affect the rate of morbidity and mortality in patients undergoing a primary anastomosis (PA) or Hartmann Procedure (HP) for perforated diverticulitis. This is a systematic review and meta-analysis, conducted according to PRISMA, with an electronic search of the PubMed, Medline, Cochrane Library, and Google Scholar databases. The search retrieved 614 studies, of which 11 were included. Preoperative-Intraoperative factors including age, ASA classification, BMI, severity of peritonitis, and comorbidities were collected. Primary endpoints were mortality and postoperative complications including sepsis, surgical site infection, wound dehiscence, hemorrhage, postoperative ileus, stoma complications, anastomotic leak, and stump leakage. 133,304 patients were included, of whom 126,504 (94.9%) underwent a HP and 6800 (5.1%) underwent a PA. There was no difference between the groups with regards to comorbidities (p = 0.32), BMI (p = 0.28), or severity of peritonitis (p = 0.09). There was no difference in mortality [RR 0.76 (0.44-1.33); p = 0.33]; [RR 0.66 (0.33-1.35); p = 0.25]. More non-surgical postoperative complications occurred in the HP group (p = 0.02). There was a significant association in the HP group between the severity of peritonitis and mortality (p = 0.01), and surgical site infection (p = 0.01). In patients with perforated diverticulitis, PA can be chosen. Age, comorbidities, and BMI do not influence postoperative outcomes. The severity of peritonitis should be taken into account as a predictor of postoperative morbidity and mortality., (© 2024. Italian Society of Surgery (SIC).)

Aim: In terms of early-term mortality, there may be variability in terms of factors belonging to age groups. While some risk factors apply to all patients undergoing colorectal cancer surgery, some factors may come to the fore in terms of age. There have been very few studies on factors that increase the risk of early-term mortality, especially for geriatric patients. It was aimed to compare factors influencing prognosis and mortality within the first 30 postoperative days between geriatric patients and those <65 years of age, and to identify factors that increase the risk of anastomotic leakage and early-term mortality, particularly in geriatric patients., Methods: Clinical, laboratory, and pathology findings from 341 patients (186 geriatric) who underwent surgery for colorectal cancer between January 2016 and December 2019 were collected and analyzed. In terms of categorical variables, comparisons between groups were made with Pearson's Chi Square test and Fisher's Exact Test. Risk coefficients of variables in terms of anastomotic leakage and early-term mortality were determined by logistic regression analysis. The results were evaluated within the 95% Confidence interval, and p < 0.05 values were considered significant., Results: Anastomotic leakage was detected in 7% of patients, and 6.2% of the patients died within the first 30 postoperative days. The 30-day postoperative mortality rate was significantly higher in geriatric patients with hypertension (p = 0.003), those undergoing emergency surgery (p = 0.007), those with stage 4 tumors (p < 0.001), those with ostomy-related complications (p = 0.042), those who developed intraabdominal abscess or peritonitis (p < 0.001), those with respiratory failure (p = 0.009), and those with perforation (p = 0.001). In patients <65 years of age, groups stratified by these variables did not differ significantly in terms of early-term mortality rate (p > 0.05 for each)., Conclusions: These findings show that lack of bowel preparation and development of intraabdominal abscess/peritonitis significantly increase early-term mortality rates in both <65 and geriatric patients. Additionally, hypertension, emergency surgery, advanced tumor stage, development of ostomy-related complications, respiratory failure, and perforation significantly increase early-term mortality solely in geriatric patients.

Objectives: Several studies have compared outcomes of peritoneal dialysis (PD) between elderly and non-elderly patients but with variable results. We hereby designed this review to compare mortality, peritonitis, and technique survival between elderly and non-elderly patients on PD., Methods: PubMed, Embase, and Google Scholar were searched for studies comparing outcomes of PD between elderly and non-elderly patients. The last search date was 14th July 2021., Results: Fourteen studies were included. 12 studies defined the elderly as ≥65 years of age and these were included in the meta-analysis. Pooled analysis of crude (RR: 2.45 95% CI: 1.36, 4.40 I2 = 97% p = 0.003) and adjusted data (HR: 2.80 95% CI: 2.45, 3.09 I2 = 0% p<0.00001) indicated a statistically significant increased risk of mortality amongst elderly patients as compared to non-elderly patients. Meta-analysis of four studies demonstrated a statistically significant increased risk of peritonitis in the elderly (RR: 1.56 95% CI: 1.18, 2.07 I2 = 76% p = 0.002). Pooled analysis demonstrated no statistically significant difference in technique survival between the two groups (RR: 0.95 95% CI: 0.86, 1.05 I2 = 86% p = 0.32)., Conclusion: Elderly patients on PD have a significantly increased risk of mortality as compared to non-elderly patients. The risk of peritonitis is also significantly increased in older adults but the increased age has no impact on technique survival. Further studies are needed to strengthen our conclusions., Competing Interests: The authors have declared that no competing interests exist.

Ascitic fluid infection (AFI) is a life-threatening complication of cirrhosis. We aimed to identify early indicators of secondary peritonitis (SP), which requires emergency surgery, and to describe the outcomes of SP and spontaneous bacterial/fungal peritonitis (SBFP). Adults with cirrhosis and AFI admitted to 16 university or university-affiliated ICUs in France between 2002 and 2017 were studied retrospectively. Cases were identified by searching the hospital databases for relevant ICD-10 codes and hospital charts for AFI. Logistic multivariate regression was performed to identify factors associated with SP. Secondary outcomes were short- and long-term mortality and survivors' functional outcomes. Of 178 included patients (137 men and 41 women; mean age, 58 ± 11 years), 21 (11.8%) had SP, confirmed by surgery in 16 cases and by abdominal computed tomography in 5 cases. Time to diagnosis exceeded 24 h in 7/21 patients with SP. By multivariate analysis, factors independently associated with SP were ascitic leukocyte count > 10,000/mm 3 (OR 3.70; 95%CI 1.38-9.85; P = 0.009) and absence of laboratory signs of decompensated cirrhosis (OR 4.53; 95%CI 1.30-15.68; P = 0.017). The 1-year mortality rates in patients with SBFP and SP were 81.0% and 77.5%, respectively (Log-rank test, P = 0.92). Patients with SP vs. SBFP had no differences in 1-year functional outcomes. This multicenter retrospective study identified two indicators of SP as opposed to SBFP in patients with cirrhosis. Using these indicators may help to provide early surgical treatment., (© 2021. The Author(s).)

Postoperative peritonitis is characterized by a more severe clinical course than other forms of secondary peritonitis. The pathophysiological mechanisms behind this phenomenon are incompletely understood. This study used an innovative model to investigate these mechanisms, combining the models of murine Colon Ascendens Stent Peritonitis (CASP) and Surgically induced Immune Dysfunction (SID). Moreover, the influence of the previously described anti-inflammatory reflex transmitted by the vagal nerve was characterized. SID alone, or 3 days before CASP were performed in female C57BL/6 N mice. Subdiaphragmatic vagotomy was performed six days before SID with following CASP. The immune status was assessed by FACS analysis and measurement of cytokines. Local intestinal inflammatory changes were characterized by immunohistochemistry. Mortality was increased in CASP animals previously subjected to SID. Subclinical bacteremia occurred after SID, and an immunosuppressive milieu occurred secondary to SID just before the induction of CASP. Previous SID modified the pattern of intestinal inflammation induced by CASP. Subdiaphragmatic vagotomy had no influence on sepsis mortality in our model of postoperative peritonitis. Our results indicate a surgery-induced inflammation of the small intestine and the peritoneal cavity with bacterial translocation, which led to immune dysfunction and consequently to a more severe peritonitis., (© 2021. The Author(s).)

For peritonitis, a serious complication of peritoneal dialysis (PD), we investigated the relation between duration from the sign (PD effluent abnormalities) to treatment with appropriate antibiotics (ST time) and catheter removal. For 62 PD hospital patients, data of PD-related peritonitis (n = 109) were collected retrospectively. We examined ST time and PD catheter removal times using univariate and multivariate analyses. The catheter removal rate in the delayed ST time group (≥ 24 h) was higher than that in early ST time group (< 24 h) (38 vs. 16%, p = 0.02). Concomitant tunnel infection and delayed ST time were associated with catheter removal (OR [95% CI] 32.3 [3.15-329] and 3.52 [1.11-11.1]). Rates of catheter removal and re-development of peritonitis within 1 month after starting treatment were higher in the delayed ST time group (p = 0.02). PD duration at peritonitis and the first peritonitis episode were associated with delayed ST time (1.02 [1.00-1.04] and 3.42 [1.09-10.7]). Significant association was found between PD catheter removal and the start of treatment more than 24 h after appearance of abnormal effluent. Education for patients about prompt visitation at the onset of peritonitis with long PD duration might improve outcomes.

Fructooligosaccharide was isolated from Polygonatum Cyrtonema Hua (PFOS) for the first time. Structure characterized using FT-IR, MALDI-TOF-MS, NMR, AFM, and TEM, indicated that PFOS was graminan-type fructan with a degree of polymerization ranging from 5 to 10. A murine model of lipopolysaccharide (LPS)-induced peritonitis was used to evaluate the in vivo anti-inflammatory and lung protective efficacy of PFOS. The result shown that pretreatment with PFOS (1.0 mg/mL) in peritonitis-induced mice could significantly inhibit the level of pro-inflammatory cytokines (TNF-α, IL-1β) in serum (P < 0.001), increase mice survival rate from 12.5 % to 54 % (P < 0.05), and alleviated lung injury through ameliorating the damage of the pulmonary cellular architecture and reducing inflammatory monocyte accumulation in lung tissue. This effect of oligosaccharides could explain the traditional usage of P. cyrtonema as a tonic medicine for respiratory problems and it could be used as a potential natural ingredient with anti-inflammatory activity., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Intra-abdominal infection (peritonitis) is a leading cause of severe disease in surgical intensive care units, as over 70% of patients diagnosed with peritonitis develop septic shock. A critical role of the immune system is to return to homeostasis after combating infection. S100A8/A9 (calprotectin) is an antimicrobial and pro-inflammatory protein complex used as a biomarker for diagnosis of numerous inflammatory disorders. Here we describe the role of S100A8/A9 in inflammatory collateral tissue damage (ICTD). Using a mouse model of disseminated intra-abdominal candidiasis (IAC) in wild-type and S100A8/A9-deficient mice in the presence or absence of S100A9 inhibitor paquinimod, the role of S100A8/A9 during ICTD and fungal clearance were investigated. S100A8/A9-deficient mice developed less ICTD than wild-type mice. Restoration of S100A8/A9 in knockout mice by injection of recombinant protein resulted in increased ICTD and fungal clearance comparable to wild-type levels. Treatment with paquinimod abolished ICTD and S100A9-deficient mice showed increased survival compared to wild-type littermates. The data indicates that S100A8/A9 controls ICTD levels and antimicrobial activity during IAC and that targeting of S100A8/A9 could serve as promising adjunct therapy against this challenging disease., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Shankar, Uwamahoro, Backman, Holmberg, Niemiec, Roth, Vogl and Urban.)

Importance: Infection in neonates remains a substantial problem. Advances for this population are hindered by the absence of a consensus definition for sepsis. In adults, the Sequential Organ Failure Assessment (SOFA) operationalizes mortality risk with infection and defines sepsis. The generalizability of the neonatal SOFA (nSOFA) for neonatal late-onset infection-related mortality remains unknown., Objective: To determine the generalizability of the nSOFA for neonatal late-onset infection-related mortality across multiple sites., Design, Setting, and Participants: A multicenter retrospective cohort study was conducted at 7 academic neonatal intensive care units between January 1, 2010, and December 31, 2019. Participants included 653 preterm (<33 weeks) very low-birth-weight infants., Exposures: Late-onset (>72 hours of life) infection including bacteremia, fungemia, or surgical peritonitis., Main Outcomes and Measures: The primary outcome was late-onset infection episode mortality. The nSOFA scores from survivors and nonsurvivors with confirmed late-onset infection were compared at 9 time points (T) preceding and following event onset., Results: In the 653 infants who met inclusion criteria, median gestational age was 25.5 weeks (interquartile range, 24-27 weeks) and median birth weight was 780 g (interquartile range, 638-960 g). A total of 366 infants (56%) were male. Late-onset infection episode mortality occurred in 97 infants (15%). Area under the receiver operating characteristic curves for mortality in the total cohort ranged across study centers from 0.71 to 0.95 (T0 hours), 0.77 to 0.96 (T6 hours), and 0.78 to 0.96 (T12 hours), with utility noted at all centers and in aggregate. Using the maximum nSOFA score at T0 or T6, the area under the receiver operating characteristic curve for mortality was 0.88 (95% CI, 0.84-0.91). Analyses stratified by sex or Gram-stain identification of pathogen class or restricted to infants born at less than 25 weeks' completed gestation did not reduce the association of the nSOFA score with infection-related mortality., Conclusions and Relevance: The nSOFA score was associated with late-onset infection mortality in preterm infants at the time of evaluation both in aggregate and in each center. These findings suggest that the nSOFA may serve as the foundation for a consensus definition of sepsis in this population.

Abstract: We aimed to investigate the hypothesis that serum triglyceride (TG) may be an independent predictor of early-onset peritonitis and prognosis in incident continuous ambulatory peritoneal dialysis (CAPD) patients.In this retrospective, observational study, we screened 291 adults admitted to the PD center of the Wuhan No. 1 hospital from August 1, 2013 to November 31, 2017. All biochemical data were collected at the first 1 to 3 months after the initiation of CAPD. Early-onset peritonitis was defined as peritonitis occurring within 6 months after the initiation of PD. All of PD patients were followed up to July 31, 2018. The primary endpoint was the incidence of early-onset peritonitis while the second endpoints included overall mortality and technical failure.A total of 38 patients occurred early-onset PD peritonitis and the Lasso logistic regression selected TG and age in the final model for early-onset peritonitis. We divided patients into two groups based on the median baseline TG levels: TG ≥ 1.4mmo/L group (n = 143) and TG < 1.4mmol/L group (n = 148). There were 34 (11.7%) patients died and 33 (11.3%) patients transferred to hemodialysis during the follow-up, Moreover, a level of TG ≥ 1.4mmol/L at the initiation of CAPD was associated with a significantly increased probability of technical failure (hazard ratio, HR, 1.30; 95% confidence interval, 95% CI, 1.09 to 2.19, P = .043) and overall mortality (HR, 2.33; 95% CI, 1.16-4.72, P = .018).Serum TG levels measured at the initiation of PD therapy is an independent predictor of early-onset peritonitis and prognosis of CAPD patients., Competing Interests: The authors declare that there are no conflicts of interest., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To compare the most common prognostic systems in patients with peritonitis., Material and Methods: The study included 352 patients with secondary peritonitis. At admission, sepsis was diagnosed in 15 (4.3%) patients, septic shock - in 4 (1.1%) cases. Mortality was associated with the following main causes: purulent intoxication and/or sepsis - 51 cases (87.9%), cancer-induced intoxication - 4 (6.9%) cases, acute cardiovascular failure - 3 cases (5.2%). We analyzed the efficacy of Manheim Peritoneal Index (MPI), WSES prognostic score, APACHE-II scale, gSOFA score and Peritonitis Prediction System (PPS) developed by the authors., Results: Age of a patient, malignant tumor, exudate nature, sepsis (septic shock) and organ failure not associated with peritonitis are the most important criteria in predicting fatal outcome. ROC analysis was used to assess prognostic value of various prediction systems. Standard error was less than 0.05 for all scales. Therefore, all prediction systems can be considered accurate for prediction of mortality in patients with peritonitis., Conclusion: PPS (AUC 0.942) has the greatest accuracy in predicting fatal outcome in patients with advanced secondary peritonitis, APACHE II (AUC 0.840) - minimum accuracy. MPI had predictive accuracy > 90% too.

Introduction: surgical complications following unsafe abortion (UA) are not uncommon and are associated with high morbidity and mortality in developing countries. The commonest need for the general surgeon following UA is after a diagnosis of peritonitis which can occur following use of sharp objects introduced through the vagina. This study aims to highlight the presentation, management types and outcome of patients who presented with peritonitis following UA., Methods: this study is a retrospective review of cases of peritonitis following UA seen over 4 years from January 2015 to December 2019 in a tertiary health facility in North Central Nigeria., Results: a total of 14 patients with peritonitis following UA were included in the study. The mean age of patients who presented was 27.4 years (19-40 years) with a mean estimated gestational age at abortion of 7.8 weeks. The average time from the UA procedure till presentation at the hospital was 8.6 days. There were 9 bowel injuries and 5 pelvic abscesses. A total of 3/9 patients had primary resection and anastomosis while 6/9 had stoma formed as part of their management. Pelvic abscesses were drained. In patients with bowel injury, those who had primary anastomosis had a 100% incidence of enterocutaneous fistula formation with associated sepsis requiring repeat exploration and formation of stoma. Mortality in this group was 67% (2/3) compared to the 0% (0/6) mortality rate seen in patients who had stoma. The overall mortality was four out of fourteen patients (28.6%)., Conclusion: peritonitis following UA is associated with marked morbidity and mortality as many of the patients present late. Initial preoperative resuscitation and stabilization should be followed by a swift laparotomy. Patients with bowel injury who had primary anastomosis had higher morbidity, reoperation rates and mortality than patients who had stomas., Competing Interests: The authors declare no competing interests., (Copyright: Adedire Timilehin Adenuga et al.)

Background: To compare patients hospitalised in the intensive care unit (ICU) after surgery for community-acquired intra-abdominal infection (CA-IAI) and hospital-acquired intra-abdominal infection (HA-IAI) in terms of mortality, severity and complications., Methods: Retrospective study including all patients admitted to 2 ICUs within 48 h of undergoing surgery for peritonitis., Results: Two hundred twenty-six patients were enrolled during the study period. Patients with CA-IAI had an increased 28-day mortality rate compared to those with HA-IAI (30% vs 15%, respectively (p = 0.009)). At 90 days, the mortality rates were 36.7 and 37.5% in the CA-IAI group and HA-IAI group, respectively, with a similar APACHE II score on admission (median: 21 [15-25] vs. 21 [15-24] respectively, p = 0.63). The patients with HA-IAI had prolonged ICU and hospital stays (median: 17 [7-36] vs. 6[3-12] days, p < 0.001 and 41 [24-66] vs. 17 [7-32] days, p = 0.001), and experienced more complications (reoperation and reintubation) than those with CA-IAI., Conclusion: CA-IAI group had higher 28-day mortality rate than HA-IAI group. Mortality was similar at 90 days but those with HA-IAI had a prolonged ICU and hospital stay. In addition, they developed more complications.

Background: As hospital sepsis mortality has decreased, more surgical ICU survivors are progressing into chronic critical illness (CCI). This study documents the incidence of CCI and long-term outcomes of patients with abdominal sepsis. We hypothesized that patients developing CCI would have biomarker evidence of immune and metabolic derangement, with a high incidence of poor 1-year outcomes., Methods: Review of abdominal sepsis patients entered in a prospective longitudinal study of surgical ICU sepsis., Results: Of the 144 study patients, only 6% died early, 37% developed CCI (defined as ICU days ≥14 with organ dysfunction) and 57% were classified rapid recovery (RAP). Compared to RAP, CCI patients a) were older (66 vs 58), males who were sicker at baseline (Charlson Comorbidity Index 4 vs 2), b) had persistently elevated biomarkers of dysregulated immunity/metabolism (IL-6, IL-8, sPDL-1, GLP1), c) experienced more secondary infections (4.9 vs 2.3) and organ failure (Denver MOF frequency 40 vs 1%), d) were much more likely to have poor dispositions (85 vs 22%) with severe persistent disabilities by Zubrod Score and e) had a notably higher 1-year mortality of 42% (all p < 0.05)., Conclusion: Over 1/3rd surgical ICU patients treated for abdominal sepsis progress into CCI and experience dismal long-term outcomes., Competing Interests: Declaration of competing interest All authors declare no conflicts of interest., (Copyright © 2020. Published by Elsevier Inc.)

Postoperative peritonitis (PoP), despite their relatively low incidence, are associated with high mortality. Such poor outcomes are also related to the high proportion of aged patients, whose intra-abdominal infections are difficult to manage. The study included 84 consecutive patients with PoP. The aim was the validation of the Mannheim Prognostic Index (MPI) in the context of PoP and the assessment of the prognostic impact of age and other clinical factors in a large series from a tertiary center. PoP had an incidence of 3.9% in all the abdominal surgeries in the study period. Surgical control of POP focus was achieved in 90.5% of cases and a complete abdominal clearance in 58.3%. Complication rate was 75% with a mortality of 26.2%. For MPI score, the ROC curve indicated a cut-off value of 29 with a sensitivity of 72.7% and specificity of 67.7% in predicting death. At univariate analysis, factors significantly related to poorer prognosis included advanced age (p 0.001), site of primary surgery (p 0.05), lack of abdominal clearance (p 0.003), generalized peritonitis (p 0.04) and high MPI score (p < 0.001). Age, MPI score and absence of abdominal clearance resulted in independent prognostic factors at multivariate analysis. MPI showed good efficacy in identifying POP patients at high risk of death. The increased risk of mortality related to advanced age should be considered with MPI score in planning the treatment. An aggressive and early diagnostic-therapeutic approach is required to reduce the MPI score and improve the prognosis.

Background: Scoring systems are needed to prognosticate, compare and audit surgical procedures. Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and morbidity (P-POSSUM) and Acute Physiological and Chronic Health Evaluation II (APACHE II) are well known and validated scores to predict surgical outcomes. The objective of this study was to compare P-POSSUM and APACHE II scores in predicting morbidity and mortality of patients who underwent emergency surgery for perforation peritonitis., Materials and Methods: A prospective single-center cohort study was conducted with a sample size of 56 patients of perforation peritonitis from November 2018 to March 2020. All patients were followed up prospectively for a period of 30 days to monitor the primary outcome variable mortality and secondary outcome variables such as wound infection, wound dehiscence, anastomotic leak, respiratory complications, Intensive Care Unit (ICU) stay and hospital stay., Results: Mean age of patients was 37.1 years and 67.86% were males. Ileum was the most common site of perforation followed by the stomach. The most common post-operative complication was wound infection (71.43%) followed by respiratory complications (64.29%) and wound dehiscence (35.71%). ICU stay was required for a majority of patients (74.42%). The mean hospital stay was 8.93 days and the mortality rate was 23.21% in this study. P-POSSUM and APACHE II scores had a good association with mortality, post-operative wound dehiscence, respiratory complications, ICU stay and hospital stay. However, there was no statistical difference between the two scores in predicting the above outcomes. Post-operative wound infection and anastomotic leak had no association with P-POSSUM or APACHE II scores., Conclusion: As the APACHE II score is based only on preoperative parameters and is easier to calculate we recommend its use for patients of perforation peritonitis over the P-POSSUM score as both have similar predictability., Competing Interests: Declaration of competing interest Authors declare that they have no conflicts of interest.Provenance and peer review, Not commissioned, externally peer-reviewed., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Efficacy and Safety of intravenous albumin for non-spontaneous bacterial peritonitis infection among patients with cirrhosis: A systematic review and meta-analysis of randomized controlled trials INTRODUCTION: Bacterial infection is a common cause of acute-on-chronic liver failure (ACLF) and death among cirrhosis. The benefit of intravenous (IV) albumin among cirrhosis with non-SBP infection remains unclear as individual studies are underpowered to detect the survival benefit of IV albumin., Aim: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of intravenous albumin for non-SBP infection among cirrhosis patients., Methods: We performed a systematic search of electronic databases (Pubmed, MEDLINE and Clinicalkey) up to 1 st December 2019. Studies evaluating IV albumin for non-SBP infection were selected. Using random effect model, the pooled odds ratio (OR), 95% confidence interval (95%CI) and heterogeneity were assessed., Results: A total of 3 RCTs (406 subjects) fulfilling the inclusion criteria among 218 citations were identified. There was no significant heterogeneity across included studies. In this meta-analysis, we found that the pooled risk of renal impairment (RI) (OR=0.58, 95%CI: 0.28-1.23, I 2 =0%), mortality at 30 days (OR=1.61, 95%CI: 0.87-3.00, I 2 =0%) as well as mortality at 90 days (OR=1.30, 95%CI: 0.81-2.07, I 2 =0%) were similar between albumin and control group. Pooled event of pulmonary edema occurred more commonly in albumin group (OR 5.17, 95%CI 1.62-16.47, I 2 =0%). More subjects achieved resolution of ACLF in IV albumin group as compared to control group (OR=0.11, 95%CI: 0.02-0.69, p=0.02)., Conclusion: Albumin did not reduce the risk of RI and mortality, yet increases the risk of pulmonary edema. Albumin may promote recovery of ACLF, however, more data is required to validate this benefit., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier Ltd.)

Objective: To study the clinico-bacteriological profile of ascitic fluid infection (AFI) and its impact on outcome in childhood chronic liver disease (CLD)., Methods: It was a retrospective study on pediatric CLD patients requiring an ascitic tap. Logistic regression was performed to study the predictive factors for AFI., Results: Two hundred and fifty-two (30.9%) of 814 children with CLD underwent ascitic tap on suspicion of AFI of whom 79 (31.3%) had AFI, culture negative neutrocytic ascites being the commonest. Younger age (p = 0.002), male gender (p = 0.007), new onset/rapid increase in ascites (p = 0.032), fever (p = 0.012), and blood total leukocyte count (TLC) (p = 0.001) were found to be independently associated with AFI. Twenty-three children had positive ascitic fluid culture: 15 Gram negative; 11 (52.3%) were multidrug resistant organism. Hepatic encephalopathy (HE) (p = 0.001), Model for End-stage Liver Disease/Pediatric End-stage Liver Disease (MELD/PELD) (p < 0.0005), and difficult-to-treat AFI (p = 0.007) were found to be independently associated with death and or LT., Conclusion: Children with ascites should undergo a diagnostic paracentesis in presence of fever, increasing or new-onset ascites, and/or increased TLC. Death or liver transplant are more likely due to advanced liver disease (high PELD /HE) and in those with difficult-to-treat AFI.

Background: Postoperative peritonitis still remains the cause of a high mortality rate in emergency abdominal surgery. Here we aimed to evaluate the efficacy of different surgical strategies for small-bowel perforations that resulted in postoperative peritonitis., Methods: Surgical management results for 140 patients with postoperative peritonitis due to small-bowel perforations, necrosis and anastomotic leakage were comparatively analyzed. Using the APACHE-II and MPI scoring systems, different surgeon attitudes were examined in three patient groups (primary anastomosis, delayed anastomosis, and enterostomy)., Results: The surgical approach in patient group I (n = 47, APACHE-II 11.7 ± 1.2, MPI 14.7 ± 1.3) involved the closure of small-bowel perforations or small-bowel resection to place primary anastomosis. The mortality rate was 17%. Patient group II (n = 48, APACHE-II 16.8 ± 0.7, MPI 19.3 ± 0.3) underwent delayed small-bowel anastomosis during planned relaparotomies. The mortality rate was 18.8%. Because patients in patient group III (n = 45, APACHE-II 22.3 ± 1.3, MPI 24.6 ± 1.2) were in very critical condition, anastomoses were not placed after bowel resection, and the surgical procedure was completed with enterostomy. The highest mortality rate of 37.8% was documented in this patient group., Conclusion: The differentiated surgical approach undertaken herein using delayed small-bowel anastomosis in more serious patients with postoperative peritonitis was able to mitigate the risk of recurrent anastomotic leaks and was not accompanied by a considerable rise in mortality. The mortality for primary repair and delayed primary closure was basically the same (17.0% and 18.8%, p = 0.03); however, delayed anastomosis in the patients with postoperative peritonitis at higher APACHE-II and MPI scores for severity of illness showed 15.1% less complications in the form of anastomotic leaks (p = 0.04).

Background: Staged lavage was first introduced in the 1970s and now serves as a therapeutic option for septic patients with peritonitis. A central aspect of this treatment concept is leaving the abdomen open after a wide incision. To evaluate the influence of transverse vs. median access to the abdomen in staged lavage, data from the authors' patients were analyzed. Methods: To evaluate patients with peritonitis, prospective intensive care data were examined together with data on the surgical details. The main aspects covered here were the surgical details of the lavage (namely, transverse vs. median laparotomy), number of lavages, fascia closure, wound-healing disorders, and observed lethality, in combination with the preoperatively evaluated SAPS-II score, expected hospital lethality, patient age, and the Mannheim Peritonitis Index. Results: Between January 2008 and December 2018, 522 patients were treated with open abdomen and staged lavage. The mean age of the patients was 66.0 years (standard deviation (SD) 15.9 years). A median incision was used in 140 cases, and transverse laparotomy was performed in 382. The mean SAPS-II score was 46.5 (SD 15.7), expected lethality was 39.6% (SD 26.3%), and observed lethality was 19.9%. On average, two lavages were performed after the index operation. Transverse incision was significantly less likely to cause wound-healing disorder (p=0.03), and fascial dehiscence was observed less frequently in the transverse laparotomies group than in median incisions in the statistical trend (p=0.06). Conclusion: In summary, staged lavage reduced expected lethality in patients with peritonitis. Transverse incision caused wound-healing disorders and fascial dehiscence less often. Therefore, the indication for transverse laparotomy should be generous, as this form of treatment is advantageous in case of peritonitis., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020 Petersen et al.)

We aim to investigate the role of A 2A receptor in peritonitis-related sepsis by injection of a fecal solution (FS) as a model of polymicrobial infection. C57/black J6 wild-type (WT) and A 2A -deficient mice (A 2A KO) were exposed to sepsis induced by intraperitoneal injection of a FS (FS-induced peritonitis) or instead was injected with saline buffer (Sham). Survival rate and sepsis score were measured up to 48 h. The presence of bacteria in tissue homogenates was analyzed. Telemetry and speckle laser Doppler were used for systemic blood pressure and peripheral blood perfusion analysis, respectively. Histological analysis and identification of active caspase 3 were performed in selected organs, including the liver. The survival rate of A 2A KO mice exposed to FS-induced peritonitis was significantly higher, and the sepsis score was lower than their respective WT counterpart. Injection of FS increases (50 to 150 folds) the number of colonies forming units in the liver, kidney, blood, and lung in WT mice, while these effects were significantly attenuated in A 2A KO mice exposed to FS-induced peritonitis. A significant reduction in both systolic and diastolic blood pressure, as well as in the peripheral perfusion was observed in WT and A 2A KO mice exposed to FS-induced peritonitis. Although, these last effects were significantly attenuated in A 2A KO mice. Histological analysis showed a large perivascular infiltration of polymorphonuclear in the liver of WT and A 2A KO mice exposed to FS-induced peritonitis, but again, this effect was attenuated in A 2A KO mice. Finally, high expression of active caspase 3 was found only in the liver of WT mice exposed to FS-induced peritonitis. The absence of the A 2A receptor increases the survival rate in mice exposed to polymicrobial sepsis. This outcome was associated with both hemodynamic compensation and enhanced anti-bacterial response.

Infections are a frequent complication and a major cause of death among patients with cirrhosis. The important impact of infections in general and especially spontaneous bacterial peritonitis on the course of disease and prognosis of patients with cirrhosis has been recognized for many years. Nevertheless, such importance has recently increased due to the comprehension of infection as one of the most prominent risk factors for patients to develop acute-on-chronic liver failure. Furthermore, the issue of infections in cirrhosis is a focus of increasing attention because of the spreading of multidrug resistant bacteria, which is an emerging concern among physicians assisting patients with cirrhosis. In the present paper, we will review the current epidemiology of infections in patients with cirrhosis and particularly that of infections caused by resistant bacteria, demonstrating the relevance of the subject. Besides, we will discuss the current recommendations on diagnosis and treatment of different kinds of infections, including spontaneous bacterial peritonitis, and we will highlight the importance of knowing local microbiological profiles and choosing empirical antibiotic therapy wisely. Finally, we will debate the existing evidences regarding the role of volume expansion with albumin in patients with cirrhosis and extraperitoneal infections, and that of antibiotic prophylaxis of spontaneous bacterial peritonitis., (Copyright © 2020 Fundación Clínica Médica Sur, A.C. Published by Elsevier España, S.L.U. All rights reserved.)

Background: There is scarce data from the Indian subcontinent on the outcomes following spontaneous bacterial peritonitis (SBP)., Aim: To study the immediate (within 30 days) and short-term mortality (31-90 days) associated with SBP and to determine the predictors of the same., Methods: This prospective observational study was done among patients with liver cirrhosis who underwent paracentesis. Patient data included age, gender, co-morbidity, cirrhosis-related complications, model of end-stage liver disease (MELD), and Child-Turcotte-Pugh (CTP) scores. SBP was diagnosed based on ascitic fluid polymorphonuclear leukocyte count > 250/mm 3 with or without ascitic fluid culture positivity., Results: Of the 870 patients with cirrhosis and ascites registered during the study period, 610 fulfilled the criteria for inclusion. Altogether, 122 patients with SBP were identified: 52 (42.6%) died, 40 (32.8%) survived without liver transplant, and 30 (24.6%) underwent liver transplantation within 3 months. Thirty-two patients (26.2%) were blood culture posi tive for bacteria and 7 (5.7%) demonstrable bacterial growth in ascitic fluid. Blood culture positivity was significantly higher in the group with immediate mortality (p < 0.0001) and was also significantly associated (p 0.005) with mortality at 3 months., Conclusion: Nearly two-fifths (42.6%) of the study cohort died within 3 months of an episode of SBP. Four-fifths of these patients died within 30 days. Blood culture positivity was significantly associated with immediate and short-term mortality.

The present study attempted to investigate the association among Type D, medication adherence and peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients. Type D personality was assessed by the Chinese 14-item Type D Personality Scale (DS14) in CAPD patients. Patients' medication adherence was assessed by the Medication Adherence Report Scale, retrospectively. Of the 385 CAPD patients who were investigated, 137 (35.6%) patients had a Type D personality. The medication adherence was significantly poorer in the Type Ds compared with that of the non-Type Ds (21.5 ± 2.8 vs. 22.5 ± 2.5 score, p = 0.002). Using multiple linear regression analysis, we found that Type D personality was independently associated with medication adherence ( β = 0.56, p < 0.05). Furthermore, the overall peritonitis-free survival rate of non-Type Ds was significantly higher than that of Type Ds ( X 2 = 4.41, p = 0.025). Using Cox regression, Type D personality (HR 1.67; 95% confidence interval [CI] 1.07-2.59; p = 0.022) and adherence to bag exchange procedure (HR 1.54; 95% CI 1.11-2.14; p = 0.009) predicted the development of the first peritonitis, even after adjustment for confounders. The current study is the first to identify a strong association among Type D, medication adherence and peritonitis in CAPD patients.

Background: Spontaneous bacterial peritonitis (SBP) is one of the most critical complications of decompensated liver cirrhosis. This study aimed to assess whether ascitic neutrophil gelatinase-associated lipocalin (NGAL), a reliable inflammation biomarker, can be used to detect SBP in decompensated cirrhosis patients and to predict mortality from decompensated cirrhosis-related SBP., Methods: This study included 204 hospitalized patients with ascites of decompensated liver cirrhosis and follow-up of 28 days. We measured ascitic NGAL levels by the latex-enhanced immunoturbidimetric method. Simultaneously, we observed the patterns of ascitic NGAL levels in the SBP group after 7 days of anti-infection treatment with third-generation cephalosporins., Results: The ascitic NGAL levels significantly increased in the SBP group compared with that in the non-SBP group, 111(83.9, 178) ng/mL vs 48(35.4, 63) ng/mL, P < .001. Likewise, the ascitic NGAL levels of SBP were higher than non-SBP with or without renal dysfunction. There was a positive relationship between ascitic NGAL and ascitic polymorphonuclear (PMN) leukocyte and a negative relationship between ascitic NGAL and ascitic albumin in the SBP group. An ascitic NGAL cutoff of 108.95 ng/mL was used for predicting a poor prognosis for SBP patients. Ascitic NGAL and the model for end-stage liver disease score were independent risk factors in decompensated liver cirrhosis patients with SBP through multivariate Cox regression. A dynamic trend of ascitic NGAL in SBP patients was consistent with the clinical prognosis., Conclusion: Ascitic NGAL may not only be a biomarker for monitoring SBP but also a predictor for more severe outcomes in decompensated cirrhosis-related SBP., (© 2020 The Authors. Journal of Clinical Laboratory Analysis published by Wiley Periodicals, Inc.)

Background & Aims: Peritoneal macrophages (PMs) regulate inflammation and control bacterial infections in patients with decompensated cirrhosis. We aimed to characterize PMs and associate their activation with outcomes of patients with spontaneous bacterial peritonitis (SBP)., Methods: We isolated PMs from ascites samples of 66 patients with decompensated cirrhosis (19 with SBP) and analyzed them by flow cytometry, quantitative real-time polymerase chain reaction, functional analysis, and RNA microarrays. We used ascites samples of a separate cohort of 111 patients with decompensated cirrhosis (67 with SBP) and quantified the soluble form of the mannose receptor (CD206) and tumor necrosis factor by enzyme-linked immunosorbent assay (test cohort). We performed logistic regression analysis to identify factors associated with 90-day mortality. We validated our findings using data from 71 patients with cirrhosis and SBP. Data from 14 patients undergoing peritoneal dialysis for end-stage renal disease but without cirrhosis were included as controls., Results: We used surface levels of CD206 to identify subsets of large PMs (LPM) and small PMs (SPM), which differed in granularity and maturation markers, in ascites samples from patients with cirrhosis. LPMs vs SPMs from patients with cirrhosis had different transcriptomes; we identified more than 4000 genes that were differentially regulated in LPMs vs SPMs, including those that regulate the cycle, metabolism, self-renewal, and immune cell signaling. LPMs had an inflammatory phenotype, were less susceptible to tolerance induction, and released more tumor necrosis factor than SPMs. LPMs from patients with cirrhosis produced more inflammatory cytokines than LPMs from controls. Activation of PMs by Toll-like receptor agonists and live bacteria altered levels of CD206 on the surface of LPMs and release of soluble CD206. Analysis of serial ascites fluid from patients with SBP revealed loss of LPMs in the early phase of SBP, but levels increased after treatment. In the test and validation cohorts, patients with SBP and higher concentrations of soluble CD206 in ascites fluid (>0.53 mg/L) were less likely to survive for 90 days than those with lower levels., Conclusions: Surface level of CD206 can be used to identify mature, resident, inflammatory PMs in patients with cirrhosis. Soluble CD206 is released from activated LPMs and increased concentrations in patients with cirrhosis and SBP indicate reduced odds of surviving for 90 days., (Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Aim: This study aimed to investigate the effect of acute kidney injury (AKI) on long-term mortality of spontaneous bacterial peritonitis (SBP) in cirrhotic patients using International Club of Ascites (ICA)-AKI criteria., Methods: A total of 157 cirrhotic patients with a first episode of SBP between 2007 and 2016 were analyzed. We investigated the long-term mortality with related risk factors of SBP in cirrhosis including the ICA-AKI criteria. The ICA-AKI stage at SBP diagnosis is evaluated by stages 0-3. Stage progression was defined as a progression of AKI to a higher stage., Results: The ICA-AKI stage at the diagnosis of SBP was stage 0 in 91 (58%), stage 1 in 33 (21%), stage 2 in 19 (12%), and stage 3 in 14 patients (9%). Stage progression within 48 h after SBP diagnosis was noted in 18 patients (12%). Multivariable analysis showed that the risk factors for overall survival were age ≥ 60 years (hazard ratio [HR] 1.74, P = 0.029), serum sodium ≤ 130 mmol/L (HR 1.3, P = 0.017), ICA-AKI stage 1 (HR 2.51, P = 0.003), ICA-AKI stage 2 or 3 (HR 3.36, P < 0.001), and stage progression at 48 h after SBP diagnosis (HR 2.57, P = 0.004). The differences in overall survival using the ICA-AKI in patients without AKI using the conventional criteria were significantly different (P = 0.019)., Conclusion: Acute kidney injury and its progression are significant risk factors for mortality in cirrhotic patients with SBP. The application of the ICA-AKI criteria is important and advantageous for early evaluation and intervention for a better prognosis in cirrhotic patients with SBP., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Intra-abdominal candidiasis (IAC) is the predominant type of invasive candidiasis with high mortality in surgical intensive care patients. The purpose of this study was to investigate the impact of appropriate source control and antifungal therapy on the outcomes of critically ill surgical patients with IAC., Methods: This was a retrospective single-center cohort study. Adult surgical patients who were admitted to the intensive care unit and diagnosed with IAC from January 1, 2003, to December 31, 2016, were enrolled. The patients' data including risk factors of IAC, infection-related information, antifungal treatment and 30-day outcomes were collected. The primary endpoint was 30-day mortality. A COX proportional hazards model was used to analyze the association between appropriate treatment and 30-day survival., Results: A total of 82 patients were included in the analysis. Of these, 45 (54.9%) were complicated with septic shock at IAC diagnosis. Types of IAC included peritonitis (61.0%), intra-abdominal abscesses (23.2%) and biliary tract infections (15.9%). Of the included patients, 53 (64.6%) received appropriate source control and 44 (53.7%) appropriate antifungal therapy. Compared with patients with neither of these treatments, appropriate source control (HR 0.08, 95% CI 0.02-0.30; P < 0.001), appropriate antifungal therapy (HR 0.14, 95% CI 0.04-0.55; P = 0.005), and a combination of these treatments (HR 0.02, 95% CI 0.00-0.08; P < 0.001) were associated with reduced risk of death within 30 days after IAC diagnosis., Conclusion: For critically ill surgical patients with IAC, both appropriate source control and appropriate antifungal therapy were associated with reduced risk of 30-day mortality, and the protective effects of the two appropriate treatments were additive.

The purpose of this study was to investigate whether pituitary adenylate cyclase-activating polypeptide (PACAP) prevents mortality due to sepsis in mice. Mice were given PACAP at designated time points before or after cecal ligation and puncture (CLP), and organ injury and mortality were investigated. Serum inflammatory and anti-inflammatory cytokine levels were assessed after CLP. Plasma corticosterone and adrenocorticotropic hormone levels were also measured. Isolated tissue macrophages (Mfs) were incubated with or without PACAP, and production of cytokines was measured. Activation of NF-κB was investigated in tissue Mfs isolated from CLP animal in the presence and absence PACAP in vitro. PACAP treatment significantly prevented acute lung injury and mortality after CLP. Plasma endotoxin levels and bacterial load were not different between PACAP-treated and nontreated groups. Increased serum TNF-α and HMGB1 levels in animals treated with vehicle were significantly blunted in PACAP-treated animals after CLP. Furthermore, serum IL-10 levels were significantly greater in the PACAP-treated group compared with the vehicle group. Production of HMGB1 and TNF-α by isolated hepatic Mfs was significantly inhibited in the presence of PACAP, whereas production of IL-10 by isolated hepatic Mfs and interstitial lung Mfs was significantly increased. Plasma corticosterone and adrenocorticotropic hormone levels were significantly greater in the animals treated with PACAP compared with vehicle after CLP. Activation of NF-κB was significantly inhibited by PACAP in the hepatic Mfs compared with other tissue Mfs. PACAP prevents mortality due to septic peritonitis by inhibiting inflammation via NF-κB activation and possible effects on the brain., (Copyright © 2020 The Authors.)

Background/aim: The aim of this study was to evaluate the clinical outcomes and identify the predictors of mortality in peritoneal dialysis patients., Materials and Methods: Medical records of all incident peritoneal dialysis (PD) patients followed up between January 2011 and May 2019 were reviewed retrospectively. All patients were followed up until death, renal transplantation, transfer to haemodialysis or the end of the study., Results: A total of 242 patients were included in the study. The incidence of peritonitis was 0.18 (ranging from 0 to 14.9) episodes per patient year. Death occurred in 28% (n: 68) of cases. Age, diabetes mellitus, malignancy and refractory heart failure were independent risk factors for all-cause mortality according to multivariate analysis. The presence of comorbid disease and diabetes mellitus and patients aged > 65 years were associated with increased risk of mortality and decreased patient survival. Peritonitis history was associated with increased risk of mortality. Between peritonitis and peritonitis-free group, there was no significant difference in Kaplan-Meier curves in terms of patient survival., Conclusion: This is the first study to define 9-year mortality predictors in PD patients in our centre. Although peritonitis is the most feared complication of PD, our study showed that peritonitis did not reduce patient survival., Competing Interests: There is no conflict of interest in this trial., (This work is licensed under a Creative Commons Attribution 4.0 International License.)

Use of open abdomen (OA) progressively acquired increasing importance with the diffusion of the damage control management of critical patients. The purpose of the present study is to identify the state of the art about the use of OA in Italy, focusing on techniques, critical issues and clinical outcomes. A prospective analysis of adult patients enrolled in the IROA, limited to the Italian participating centres was performed. 375 patients were enrolled. Mean age was 64 ± 16 years old, 56% of the patients were male, mean BMI was 26.9 ± 5.2. Main indications for using OA were secondary peritonitis (32.5%), post-operative peritonitis (22.9%) and trauma (11.7%). Main OA techniques used were commercial negative pressure wound therapy (49.6%) and Bogotà bag (27.7%). Definitive closure of the abdomen was reached in 82.4% of patients after 6 ± 7 days of OA. The primary fascia closure rate was 84.7%. Overall mortality was 29.1%. The complication rate was 50.8%, with an enteroatmospheric fistula incidence: 7.5%. A univariate analysis performed on complication type found the duration of OA treatment (p = 0.024) to be statistically significant. Univariate analysis on mortality risk identified as significant age, duration of OA (in days) and pancreatitis as indication; multivariate analysis confirmed age (p < 0.001) and pancreatitis (p = 0.002) as statistically significant. A large variety of behaviours towards the patient requiring OA exists. A strong acceptance of common, recognized and evidence-based guidelines is essential, to obtain more uniformity in patient management and coherence of collected data, thus leading to improvement in outcomes and reduction of costs.

Diffuse peritonitis represents a life-threatening complication of acute appendicitis (AA). Whether laparoscopy is a safe procedure and presents similar results compared with laparotomy in case of complicated AA is still a matter of debate. The objective of this study is to compare laparoscopic (LA) and open appendectomy (OA) for the management of diffuse peritonitis caused by AA. This is a prospective multicenter cohort study, including 223 patients with diffuse peritonitis from perforated AA, enrolled in the Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) study from February to May 2018. Two groups were created: LA = 78 patients, mean age 42.51 ± 22.14 years and OA = 145 patients, mean age 38.44 ± 20.95 years. LA was employed in 34.98% of cases. There was no statically significant difference between LA and OA groups in terms of intra-abdominal abscess, postoperative peritonitis, rate of reoperation, and mortality. The wound infection rate was higher in the OA group (OR 21.63; 95% CI 3.46-895.47; P = 0.00). The mean postoperative hospital stay in the LA group was shorter than in the OA group (6.40 ± 4.29 days versus 7.8 ± 5.30 days; P = 0.032). Although LA was only used in one-third of cases, it is a safe procedure and should be considered in the management of patients with diffuse peritonitis caused by AA, respecting its indications.

Objectives: To investigate the risk factors associated with early-onset peritonitis (EOP) and their influence on patients' technique survival and mortality., Study Design: Retrospective, cohort study., Setting: Three peritoneal dialysis (PD) units in Shanghai., Participants: PD patients from 1 June 2006 to 1 May 2018 were recruited and followed up until 31 December 2018. According to time-to-first episode of peritonitis, patients were divided into non-peritonitis (n=144), EOP (≤6 months, n=74) and late-onset peritonitis (LOP) (>6 months, n=139)., Primary and Secondary Outcome Measures: EOP was defined as the first episode of peritonitis occurring within 6 months after the initiation of PD. The outcomes were all-cause mortality and technique failure., Results: Of the 357 patients, 74 (20.7%) patients developed their first episode of peritonitis within the first 6 months. Compared with the LOP group, the EOP group had older ages, more female patients, higher Charlson Comorbidity Index (CCI) score, lower serum albumin levels and renal function at the time of initiation of PD, and higher diabetes mellitus and peritonitis rates (p<0.05). Staphylococcus was the most common Gram-positive organism in both EOP and LOP groups. The multivariate logistic regression analysis showed that factors associated with EOP included a higher CCI score (OR 1.285, p=0.011), lower serum albumin level (OR 0.924, p=0.016) and lower Kt/V (OR 0.600, p=0.018) at start of PD. In the Cox proportional-hazards model, EOP was more likely a predictor of technique failure (HR 1.801, p=0.051). There was no difference between EOP and LOP for all-cause mortality., Conclusion: A higher CCI score and lower serum albumin level and Kt/V at PD initiation were significantly associated with EOP. EOP also predicted a high peritonitis rate and poor clinical outcome., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The objective of this study is to determine factors associated with poor outcomes and the need for surgical treatment in neonates with meconium peritonitis (MP)., Methods: We evaluated the association between prenatal ultrasound features, maternal characteristics, and the likelihood of surgery, mortality, and serious morbidity in 49 neonates with a prenatal diagnosis of MP, who were born in Guangzhou Women and Children's Medical Center between January 2011 and December 2016., Results: Thirty of 49 neonates (61.2%) required surgical treatment, and 17 (34.7%) had a poor outcome. Independent predictors of need for surgical treatment were polyhydramnios, maternal intrahepatic cholestasis of pregnancy (associated with lower risk), and persistence of peritoneal fluid. The model correctly predicted 70.0% of the neonates who required surgery (at a 10% false-positive rate; area under the curve [AUC]: 0.86 [95% CI, 0.75-0.97]). For poor outcomes, independent predictors were low gestational age at birth, persistence of peritoneal fluid, and polyhydramnios. For the latter, the model only achieved a detection rate of 52.9% (10% false-positive rate, AUC: 0.82 [95% CI, 0.70-0.94])., Conclusions: A combination of prenatal ultrasound features and maternal characteristics correctly predicted 70.0% the need for neonatal surgery. Prediction of poor outcome-based prenatal ultrasound features and gestational age did not perform well., (© 2019 John Wiley & Sons, Ltd.)

Background: Rifaximin has been shown to reduce the incidence of hepatic encephalopathy and other complications in patients with cirrhosis. However, few studies have investigated the effect of rifaximin in cirrhotic patients with refractory ascites., Aim: To evaluate the effects of rifaximin in the treatment of refractory ascites and to preliminarily explore its possible mechanism., Methods: A total of 75 cirrhotic patients with refractory ascites were enrolled in the study (50 in a rifaximin and 25 in a control group). Patients in the rifaximin group were divided into two subgroups according to the presence of spontaneous bacterial peritonitis and treatment with or without other antibiotics (19 patients treated with rifaximin and 31 patients treated with rifaximin plus intravenous antibiotics). All patients received conventional treatment for refractory ascites, while patients in the rifaximin group received oral rifaximin-α 200 mg four times daily for at least 2 wk. The ascites grade, fasting weight, liver and kidney function, and inflammatory factors in the plasma were evaluated before and after treatment. In addition, the gut microbiota was determined by metagenomics sequencing to analyse the changes in the characteristics of the gut microbiota before and after rifaximin treatment. The patients were followed for 6 mo., Results: Compared with the control group, the fasting weight of patients significantly decreased and the ascites significantly subsided after treatment with rifaximin ( P = 0.011 and 0.009, respectively). The 6-mo survival rate of patients in the rifaximin group was significantly higher than that in the control group ( P = 0.048). The concentration of interferon-inducible protein 10 decreased significantly in the rifaximin group compared with that in the control group ( P = 0.024). The abundance of Roseburia , Haemophilus , and Prevotella was significantly reduced after rifaximin treatment, while the abundance of Lachnospiraceae&#95;noname , Subdoligranulum , and Dorea decreased and the abundance of Coprobacillus increased after treatment with rifaximin plus intravenous antibiotics. The gene expression of virulence factors was significantly reduced after treatment in both subgroups treated with rifaximin or rifaximin plus intravenous antibiotics., Conclusion: Rifaximin mitigates ascites and improves survival of cirrhotic patients with refractory ascites. A possible mechanism is that rifaximin regulates the structure and function of intestinal bacteria, thus improving the systemic inflammatory state., Competing Interests: Conflict-of-interest statement: All authors declare no conflict of interest. Additionally, they have substantially contributed to this current study and approved the content of the manuscript., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Recent evidence cautions against the use of non-selective beta-blockers (NSBB) in patients with refractory ascites or spontaneous bacterial peritonitis while other data suggests a survival benefit in patients with advanced liver disease. The aim of this study was to describe the use and impact of NSBB in patients with cirrhosis referred for liver transplantation., Methods: A single-center cohort of patients with cirrhosis, who were referred and evaluated for liver transplantation between January and June 2012 were studied for baseline characteristics and clinical outcomes. Patients were grouped according to the use of NSBB at initial evaluation, with the endpoint of 90-day mortality., Results: Sixty-five (38%) of 170 consecutive patients evaluated for liver transplantation were taking NSBB. Patients taking NSBB had higher MELD and Child Pugh score. NSBB use was associated with lower 90-day mortality (6% vs. 15%) with a risk adjusted hazard ratio of 0.27 (95%CI .09-0.88, p = .03). Patients taking NSBB developed acute kidney injury (AKI) within 90 days more frequently than patients not taking NSBB (22% vs 11%), p = 0.048). However, this was related to increased stage 1 AKI episodes, all of which resolved. Twelve (27%) of 45 patients with > 90 day follow up discontinued NSBB, most commonly for hypotension and AKI, had increased subsequent MELD and mortality., Conclusions: NSBB use in patients with cirrhosis undergoing liver transplant evaluation is associated with better short-term survival. Nevertheless, ongoing tolerance of NSBB in this population is dynamic and may select a subset of patients with better hemodynamic reserve.

Background: The outcomes of culture-negative peritonitis in peritoneal dialysis (PD) patients have been reported to be superior to those of culture-positive peritonitis. The current study aimed to examine whether this observation also applied to different subtypes of culture-positive peritonitis., Methods: This multicentre registry study included all episodes of peritonitis in adult PD patients in Australia between 2004 and 2014. The primary outcome was medical cure. Secondary outcomes were catheter removal, hemodialysis transfer, relapsing/recurrent peritonitis and peritonitis-related death. These outcomes were analyzed using mixed effects logistic regression., Results: Overall, 11,122 episodes of peritonitis occurring in 5367 patients were included. A total of 1760 (16%) episodes were culture-negative, of which 77% were medically cured. Compared with culture-negative peritonitis, the odds of medical cure were lower in peritonitis caused by Staphylococcus aureus (adjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.52-0.73), Pseudomonas species (OR 0.20, 95% CI 0.16-0.26), other gram-negative organisms (OR 0.48, 95% CI 0.41-0.56), polymicrobial organisms (OR 0.30, 95% CI 0.25-0.35), fungi (OR 0.02, 95% CI 0.01-0.03), and other organisms (OR 0.61, 95% CI 0.49-0.76), while the odds were similar in other (non-staphylococcal) gram-positive organisms (OR 1.11, 95% CI 0.97-1.28). Similar results were observed for catheter removal and hemodialysis transfer. Compared with culture-negative peritonitis, peritonitis-related mortality was significantly higher in culture-positive peritonitis except that due to other gram-positive organisms. There was no difference in the odds of relapsing/recurrent peritonitis between culture-negative and culture-positive peritonitis., Conclusion: Culture-negative peritonitis had superior outcomes compared to culture-positive peritonitis except for non-staphylococcal gram-positive peritonitis.

Background and Aims: Recent years have shown a rise in occurrence of multidrug resistant ascitic fluid infection (AFI) including resistant to third generation cephalosporins. Our aim was to find the prevalence, antibiotics resistance and outcome of AFI in children with liver disease., Methods: Children (≤ 18 years) with liver disease-related ascites were prospectively enrolled from April 2015 to October 2017. Based on the results of ascitic fluid examination and culture, patients were classified as having AFI [spontaneous bacterial peritonitis (SBP), culture negative neutrocytic ascites (CNNA) and monomicrobial non-neutrocytic bacterascites (MNB)] and no-AFI. AFI diagnosed after 48 h of index hospitalization was considered as nosocomial., Results: We enrolled 194 children with a median age of 85 [2-216] months. Chronic liver disease was the commonest etiology (153, 79%). AFI was present in 60 (31%) children [SBP (n = 13), CNNA (n = 39), MNB (n = 8)] of which 53% were nosocomial and resulted in high in-hospital mortality. Gram-negative bacilli dominated the ascitic fluid culture (12/21, 57%) and 10/12 (83%) of them were extended spectrum beta-lactamases (ESBL) producers. Six (60%) ESBL producers were sensitive to cefoperazone-sulbactam and 70% to carbapenems. Child-Pugh-Turcotte (CPT) score of ≥ 11 independently determined in-hospital mortality in children with AFI., Conclusions: AFI was found in 31% children with liver disease and almost half of them were nosocomial resulting in high mortality. ESBL producing Gram-negative bacteria were the most frequently isolated organisms. Cefoperazone-sulbactam or carbapenems may be useful empirical antibiotics in nosocomial setting. Children with AFI and CPT score ≥ 11 should be evaluated for liver transplantation.

Purpose of Review: Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. Clinical trials should help guide and improve the management of cIAIs. However, inappropriate selection or measurement of outcomes in cIAIs clinical trials can lead to misleading results on the effectiveness of interventions. This review aims to describe how outcomes are reported in randomized controlled trials evaluating antibiotic treatment for cIAIs and discuss how outcome reporting may be improved., Recent Findings: Commonly used primary outcomes are treatment success or failure, and these outcomes are endorsed by regulatory bodies. However, a consensus objective definition of either is not available and current measures are prone to bias. Variation exists in timing of outcome evaluation and analysis populations, which can lead to further bias. Use of core outcome sets can help standardize outcome reporting., Summary: Inconsistency in outcome selection and reporting can lead to misleading results and impedes meta-analysis of data. Further progress, engaging clinical trialists, regulatory authorities, clinicians and patients is required to achieve consensus on which outcomes should be reported and how and when to measure them.

The presence of bacterial species other than the pathogen at infection site can affect the progression of a bacterial infection. Based on the fact that Citrobacter freundii can coexist during Pseudomonas aeruginosa infection, this study aims to investigate the impact of the co-existing C. freundii on the pathogenesis of P. aeruginosa infection. A murine peritonitis model was used to compare the mortality rates and histopathology of P. aeruginosaPAO1 infection in the presence and absence of a C. freundii clinical isolate C9. We also investigated the intercellular interaction between PAO1 and C9 by examining pyocyanin production and comparing gene expression levels. The results demonstrate that co-infection with C9 significantly increased the mortality rate and tissue damages in PAO1 infected mice. At an inoculum of 10 6 CFU, no mortality was observed in the C9 infected group at three days post-infection, whereas the mortality rate in the PAO1-C9 co-infection group was 64%, compared with 24% in the PAO1 infected group. Pyocyanin production in P. aeruginosa PAO1 increased 8 folds approximately in the presence of C. freundii C9, and operons associated with phenazine synthesis, phzA1 and phzA2, were also upregulated. Disruption of the phzA1 and phzA2 eliminated the exacerbated pathogenicity in the co-infection group, indicating that the elevated pyocyanin production was the main contributing factor. The results suggest that co-existing C. freundii during P. aeruginosa infection can exacerbate the pathogenicity, which may have significant implications in patients infected with these bacteria., (Copyright © 2019 Elsevier GmbH. All rights reserved.)

Background: Alterations in the lipid profile are part of the acute phase response, this corresponds to the so-called lipemia of sepsis., Objective: To determine if the serum level of high density lipoprotein (HDL) is related to severity and mortality., Method: Retrospective, descriptive, cross-sectional study of patients diagnosed with abdominal sepsis. During the period from April 2016 to February 2017. The severity was determined by APACHE II, SOFA, Mannheim, CONUT, the presence of organic faults and mortality., Results: We included 154 cases, 59 female and 95 male; The main organ causing abdominal sepsis was the appendix 41.6%. The overall mortality was 14.3%. The presence of organic faults was 35.1%. The mean HDL level was 37.64 mg/dl (SD ± 16.16). The findings, subjected to statistical verification by Student's t-test, showed significance among the cases with SOFA > 4 (p = 0.01) and Mannheim > 26 (p = 0.001), CONUT > 6 (p = 0.001), presence of organic failures (p = 0.001), and mortality (p = 0.003)., Conclusions: HDL levels are related to severity, with the development of organic failures and mortality in sepsis., (Copyright: © 2020 Permanyer.)

Typhoid fever caused by Salmonella enterica serovar Typhi (S.Typhi) continues to be a major problem, especially in developing countries. Due to the rapid emergence of multi-drug-resistant (MDR) strains, which limits the efficacy of conventional antibiotics as well as problems associated with the existing vaccines, efforts are being made to develop effective prophylactic agents. CdtB subunit of typhoid toxin was selected for assessing its vaccine potential due to its high conservation throughout the Typhi strains. In-vitro assessment of DNase activity of cloned and purified CdtB protein showed a significant decrease in the band intensity of DNA. The measure of metabolic activity and morphological alterations assessed using different cell lines in the presence of CdtB protein showed no significant signs of toxicity. These observations were further strengthened by cell cycle analysis, assessed by flow cytometry. Keeping these observations in mind, the immunoprotective potential of CdtB was assessed using S.Typhi induced mouse peritonitis model. A significant titer of IgG antibodies (>128000) against CdtB protein was recorded in the immunized mice by enzyme-linked immunosorbent assay (ELISA), which was also validated by immunoblotting. Active immunization with the protein protected 75% mice against a lethal dose of S.Typhi Ty2. The data indicated a significant (up to 5 log) reduction in the bacterial load in the spleen and liver of immunized-infected mice compared to control (unimmunized-infected) mice which might have resulted in the modulation of histoarchitecture of spleen and liver and the levels of cytokines (IL-6, TNF-α and IL-10) production; thereby indicating the effectiveness of the subunit. The observations deduced from the study give the proof of concept of immunogenic potential of protein. However, further studies involving the immunoreactivity of CdtB with the statistically significant number of sera samples obtained from the human patients would be helpful in establishing the relevance of CdtB protein in humans and for making the strategies to develop it as an effective vaccine candidate.