To describe data on epidemiology, microbiology, clinical characteristics and outcome of adult patients admitted in the intensive care unit (ICU) with secondary peritonitis, with special emphasis on antimicrobial therapy and source control. Post hoc analysis of a multicenter observational study (Abdominal Sepsis Study, AbSeS) including 2621 adult ICU patients with intra‐abdominal infection in 306 ICUs from 42 countries. Time-till-source control intervention was calculated as from time of diagnosis and classified into ‘emergency’ (< 2 h), ‘urgent’ (2–6 h), and ‘delayed’ (> 6 h). Relationships were assessed by logistic regression analysis and reported as odds ratios (OR) and 95% confidence interval (CI). The cohort included 1077 cases of microbiologically confirmed secondary peritonitis. Mortality was 29.7%. The rate of appropriate empiric therapy showed no difference between survivors and non-survivors (66.4% vs. 61.3%, p = 0.1). A stepwise increase in mortality was observed with increasing Sequential Organ Failure Assessment (SOFA) scores (19.6% for a value ≤ 4–55.4% for a value > 12, p < 0.001). The highest odds of death were associated with septic shock (OR 3.08 [1.42–7.00]), late-onset hospital-acquired peritonitis (OR 1.71 [1.16–2.52]) and failed source control evidenced by persistent inflammation at day 7 (OR 5.71 [3.99–8.18]). Compared with ‘emergency’ source control intervention (< 2 h of diagnosis), ‘urgent’ source control was the only modifiable covariate associated with lower odds of mortality (OR 0.50 [0.34–0.73]). ‘Urgent’ and successful source control was associated with improved odds of survival. Appropriateness of empirical antimicrobial treatment did not significantly affect survival suggesting that source control is more determinative for outcome. 

/pdf/poor-timing-and-failure-of-source-control-are-risk-factors-17h683r9.pdf

Poor timing and failure of source control are risk factors for mortality in critically ill patients with secondary peritonitis

Personalized antimicrobial policies in severe peritonitis: opportunities not to be missed!

Summary Background Diffuse peritonitis is a severe disease with high mortality and morbidity rates. Therapy is fundamentally surgical. It is important to identify patients with a significantly worse prognosis and patients who may benefit from more aggressive surgical and postsurgical care such as NPWT (Narrow Pressure Wound Therapy) prior to surgery. We tried to identify a determining factor for higher morbidity and mortality rates resulting in a worse prognosis among initial data and patient comorbidities in order to focus therapy towards more aggressive surgical management. Methods In a group of 274 patients with diffuse peritonitis, we evaluated the type of peritonitis according to effusion, origin, surgery type, and the age, gender, and present comorbidities of the patients, and compared it with the overall mortality, morbidity rate, and duration of hospitalization. Results Patients without comorbidities had a significantly lower burden in both morbidity and mortality. We recorded the highest difference in mortality in patients with two or more comorbidities, with pulmonary and cardiovascular diseases, with malignancy and hypertension. Morbidity was found to be significantly exacerbated by the presence of two or more severe diseases, cardiovascular disease, malignancy, and hypertension. Conclusion We identified age, effusion type, and the presence of comorbidities as key factors for the prognosis of our patients—the morbidity and mortality rates were substantially increased in patients with two or more comorbidities, as well as by the presence of cardiovascular disease, malignancy, and hypertension. A more aggressive approach should be considered to improve the prognosis in these patients. 

/pdf/prognostic-significance-of-comorbidities-in-patients-with-250b73wj.pdf

Prognostic significance of comorbidities in patients with diffuse peritonitis

Background. Radical changes in clinical practice along with the introduction of new surgical interventions and the new concept of precision medicine justify the need to update the traditional scales for assessing the condition of patients with peritonitis. 
Aim: to establish risk factors for the development of peritonitis in patients who were operated on for acute diseases of the abdominal cavity. 
Material and methods. The study involved 139 patients who were operated on for acute diseases of the abdominal cavity, among whom 71 had acute appendicitis, 51 had acute cholecystitis, 10 had a perforated stomach or duodenal ulcer, others had perforation of a tumor or small intestine, a pinched hernia, cryptogenic peritonitis. Depending on the number of points on the modified APACHE II scale, patients were divided into two groups: 1st group - 1-3 points (63 people, 45.3%) and 2nd group - 4 or more points (76 people, 54.7%).Statistical processing of the research results was carried out using the EZR v.1.54 program (graphical user interface for R statistical software version 4.0.3, R Foundation for Statistical Computing, Vienna, Austria). 
Results. Comparison of study groups showed that the more severe course of peritonitis was more common in men, had a greater prevalence, fibrous and purulent nature of the exudate, and was more often in the toxic stage. Patients of the second group were 6.5 years older (p=0.029), stayed longer in the hospital (by 2 days; p=0.002) and had a longer duration of surgery (by 25 minutes; p<0.001), a higher body temperature during hospitalization (by 0.4oC; p=0.008), which normalized one day later (p<0.001), as well as a lower ptrothrombin index (PTI) with higher values of international normalized ratio (INR) and prothrombin time (p<0.05), higher leukocytosis (p<0.001) and erythrocyte sedimentation rate (p=0.042) in comparison with the patients of the first group. Univariante regression analysis confirmed a positive effect on the risk of severe peritonitis of age, male gender, body temperature, pulse rate, EMN, and leukocytosis, and a negative effect of PTI value. 
Conclusion. The following risk factors for severe peritonitis were identified: male sex and age, higher temperature at hospitalization and heart rate, higher PTI and INR, as well as higher leukocytosis.

Risk factors of severe peritonitis in surgical patients

Abstract. Introduction. One of the most challenging problems of surgery is peritonitis, which can be a complication of acute inflammatory diseases of the abdominal cavity and is accompanied by high mortality. The development of prognostic models of peritonitis is a modern task of precision medicine. 
Aim. To determine the risk of severe peritonitis in patients undergoing surgery for acute abdominal diseases. 
Materials and methods. The study involved 139 patients who had been operated on for acute abdominal diseases (acute appendicitis and cholecystitis, perforated gastric or duodenal ulcer, etc.). Depending on the number of points on the modified APACHE II scale, patients were divided into two groups: Group 1 - 1-3 points (63 patients, 45.3%) and Group 2 - 4 or more points (76 patients, 54.7%). The rs1927911, rs2149356 and rs4986790 polymorphisms were determined by polymerase chain reaction using the Gene Amp® PCR System 7500 amplifier (Applied Biosystems, USA) and TaqMan Mutation Detection Assays Life-Technology (USA). Statistical processing of the study results was performed using the EZR v.1.54 software (Vienna, Austria). 
Results. Univariate regression analysis revealed a higher (p=0.008) risk of severe peritonitis for men (OR 2.56; 95% CI 1.29-5.11) compared with women; an increase (p=0.031) in the risk of severe peritonitis with patient age (OR 1.02; 95% CI 1.00-1.05). The risk of severe peritonitis increased (p<0.05) with higher admission temperature, heart rate, international normalised ratio, and leukocytosis. A reduction (p=0.009) in the risk of severe peritonitis was found with a higher prothrombin index (OR 0.95; 95% CI 0.92-0.99). In addition, a decrease (p=0.015) in the risk of severe peritonitis was found in carriers of the G/A+A/A rs1927911 heterozygote of the TLR4 gene (OR 0.42; 95% CI 0.21-0.84) compared with carriers of the ancestral G/G genotype. The multivariate model included the rs1927911 genotype, age, sex, heart rate, and leukocytosis (AUC=0.83; 95% CI 0.75-0.89; p<0.001); the model sensitivity was 68.4% (95% CI 56.7%-78.6%), and specificity was 88.9% (95% CI 78.4%-95.4%). 
Conclusion. Thus, prognostic risk factors for severe peritonitis were identified and a mathematical model for its prediction was developed using clinical, laboratory and genetic parameters.

pdf/prediction-of-the-risk-of-severe-peritonitis-in-acute-16ksgqreq6.pdf

Prediction of the risk of severe peritonitis in acute inflammatory diseases of the abdominal cavity

Background Therapeutic failure is a frequent issue in the management of post-operative peritonitis. Objectives A post hoc analysis of the prospective, multicentre DURAPOP trial analysed the risk factors for failures in post-operative peritonitis following adequate source control and empirical antibiotic therapy in critically ill patients. Patients and methods Overall failures assessed post-operatively between Day 8 and Day 45 were defined as a composite of death and/or surgical and/or microbiological failures. Risk factors for failures were assessed using logistic regression analyses. Results Among the 236 analysed patients, overall failures were reported in 141 (59.7%) patients, including 30 (12.7%) deaths, 81 (34.3%) surgical and 95 (40.2%) microbiological failures. In the multivariate analysis, the risk factors associated with overall failures were documented piperacillin/tazobactam therapy [adjusted OR (aOR) 2.10; 95% CI 1.17-3.75] and renal replacement therapy on the day of reoperation (aOR 2.96; 95% CI 1.05-8.34). The risk factors for death were age (aOR 1.08 per year; 95% CI 1.03-1.12), renal replacement therapy on reoperation (aOR 3.95; 95% CI 1.36-11.49) and diabetes (OR 6.95; 95% CI 1.34-36.03). The risk factors associated with surgical failure were documented piperacillin/tazobactam therapy (aOR 1.99; 95% CI 1.13-3.51), peritoneal cultures containing Klebsiella spp. (aOR 2.45; 95% CI 1.02-5.88) and pancreatic source of infection (aOR 2.91; 95% CI 1.21-7.01). No specific risk factors were identified for microbiological failure. Conclusions Our data suggest a predominant role of comorbidities, the severity of post-operative peritonitis and possibly of documented piperacillin/tazobactam treatment on the occurrence of therapeutic failures, regardless of their type.

Risk factors for therapeutic failure in the management of post-operative peritonitis: a post hoc analysis of the DURAPOP trial

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Risk factors for therapeutic failure in the management of post-operative peritonitis: a post hoc analysis of the DURAPOP trial