July 6, 2020

An article review from the ESICM Journal Review Club

Variables Predicting and Affecting Post-operative Intra Abdominal Infections (IAI)

Post-operative IAI contribute to increased expenses, length of stay, mortality and healthcare associated infections, along with worsening of pre-existing multi-organ dysfunctions documented secondary to infections. This is in addition to unanswered questions on the timing of interventions, classification and finer points of prescribing antimicrobials in a predominantly polymicrobial sepsis.

The authors’ review attempts to delineate variables affecting the same in terms of outcomes and prognosis. Post-operative peritonitis is documented as the most common infection. While length of hospitalisation, immunosuppressive use and exposure to broad spectrum antibiotics earlier are a few significant variables worsening the prognosis, peri-operative cultures remain clinically insignificant.

In addition to upper GI, origin of peritonitis and intraoperative cardiac failure contribute to intra-abdominal candidiasis, which will be defined further by the FUNDICU trial.

A clinical classification has been proposed in the form of post-operative intra-abdominal abscess, post-operative secondary (nosocomial) peritonitis and tertiary peritonitis, and they are further differentiated with variable treatment options with interventions required for the first two, and possibly none for the latter.

Timing and adequacy of source control in treatment remain debatable, with no clear-cut answers and an early intervention favouring those with hemodynamic instability.

USG and CT guided drainage can be attempted in selected patients with good results. In addition, surgical strategies, such as relaparotomy (planned/on demand {36-48 hr of postoperative duration}) and an open abdomen approach can be attempted.

Efficacy of antibiotics in post-operative IAI is doubtful at best, and broad-spectrum antibiotics, including cover for resistant ESBLs, are recommended. Early administration (within one hour) and duration of five days (in stable subgroups) and eight days in critically ill patients is recommended.

Procalcitonin remains an unreliable marker for de-escalation in these subsets. In post-operative IAIs, echinocandins (10-14 days) should be added to empirical regimen in critically ill subgroups with de-escalation to fluconazole, once the patient is stable.

Strengths:

The strengths of the communication include a novel definition for post-operative IAIs and a sub-classification with treatment interventions, as per current prevalent literature, along with a brief overview of prescribing antifungals and newer antibiotics in afore-mentioned sub-sets.

Limitations:

The limitations of the review include the lack of comparison of surgical interventions studies and using references with respect to specific aetiologies of abdominal infections (such as gastroduodenal perforations/mesocolic perforations/acute appendicitis/bariatric surgeries).

A word on damage control surgery in peritonitis could have been discussed.

In addition, a small focus could have been provided on peritoneal fluid culture techniques and defining intraperitoneal specimens for cultures, along with a word on other biomarker performances in IAIs and therapeutic drug monitoring in IAI.

TAKE HOME MESSAGES

Major variables which influence outcomes in IAI are site of origin, older age and presence of septic shock with immunosuppressive usage being added to above.

Local epidemiology should be kept in mind while prescribing antimicrobials for these subgroups and it brings to fore the coordination between microbiologist, ID physicians and intensive care physicians.

To conclude, we should have better markers for sepsis and fungal infections in these subsets to decide on therapeutic interventions.

 

This article review was prepared and submitted by Dr Nikhilesh Jain, CHL Hospital Indore (Madhya Pradesh), India, on behalf of the ESICM Journal Review Club.


REFERENCES
  1. World Journal of Emergency Surgery 2017;12:22: Management of Intra-Abdominal Infections: recommendations by the WSES 2016 Consensus Conference
  2. Surg Infect (Larchmt). 2017;18:1-76: The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection
  3. World Journal of Emergency Surgery 2014;9:37: Complicated intra-abdominal infections worldwide: the definitive data of the CIAOW Study

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