Factor influencing outcome of source control in the management of complicated intra-abdominal infection in Cipto Mangunkusumo University Hospital

Outcomes for complicated intra-abdominal infection are influenced by operation for source control, patient-related factors, and medical management, including antibiotic treatment. We analyzed length of stay (LOS) at 33 hospitals for 2,150 patients discharged between February 2002 and June 2003, who were >18 years, had intra-abdominal infection, and received one of 6 first-line antimicrobials. A regression tree analysis selected important variables, their interactions, and their order of significance in explaining LOS. A linear mixed model evaluated the difference in LOS between treatment groups. Adjusted LOS was calculated by the least squares means from the model and was used to assess treatment differences. Mean LOS analyzed by initial antimicrobial therapy and stratified by diagnosis showed LOS for ampicillin/sulbactam and ertapenem to be significantly shorter from levofloxacin, ceftriaxone, and piperacillin/tazobactam (all P < 0.05). Adjusting for all other factors, the variables associated with severity (e.g., diagnosis, ICU stay, and comorbidities) had the greatest impact on adjusted LOS (all P < 0.001). Our findings indicate ampicillin/sulbactam and ertapenem were associated with shorter hospital stays, which may be explained by unaccounted for underlying severity of infection and/or by surgeons stratifying antimicrobial selection according to severity of illness.

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1006. Do Antibiotic Choices Made in the ED Influence Inpatient Therapy?

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.870 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S354-S354

Author(s):

Travis M Jones ◽

Elizabeth Dodds Ashley ◽

Melissa D Johnson ◽

Rebekah W Moehring ◽

Christina Sarubbi ◽

...

Keyword(s):

Antibiotic Use ◽

Transitions Of Care ◽

University Hospital ◽

Day Length ◽

Clinical Indication ◽

Inpatient Setting ◽

Prescribing Practices ◽

Entry Length ◽

Abdominal Infection ◽

Intra Abdominal Infection

Abstract Background Inappropriate antibiotic use (AU) is common among inpatients and may begin in the emergency department (ED). ED clinicians often make the first antibiotic decisions in patient care, but it is unknown whether or not these decisions influence inpatient AU. Understanding prescribing practices at transitions of care is critical for implementing effective stewardship initiatives. Methods We performed a retrospective cohort study of AU in patients admitted to Duke University Hospital through the ED between July and December 2018. Included encounters had a minimum 2-day length of stay and received an antibiotic in both the ED and inpatient setting. Individual encounter IDs were used to link ED and inpatient AU reports generated from the DASON Antimicrobial Stewardship Assessment Portal. We compared the last ED administration date/time to the first inpatient unit administration for each agent. An antibiotic started in the ED was considered continued upon admission if the first inpatient administration occurred within 30 hours following the last ED administration. Demographic, clinical indication on order entry, length of therapy, and prescriber data were also collected. Results We included 3,336 encounters and 2,940 unique patients in the analysis. The median (IQR) patient age was 60 (42–72) years, and the most common indications for AU in the ED were sepsis (23.1%), pneumonia (17.8%), ABSSSI (15.5%), and intra-abdominal infection (12.8%). At least one antibiotic initiated in the ED was continued upon admission within 30 hours in 2,495 (74.8%) encounters. The most common antibiotics continued upon admission were piperacillin/tazobactam (32.8%), vancomycin (24.9%), and ceftriaxone (13.7%). The most common indications for agents continued upon admission were pneumonia (18%), intra-abdominal infection (15%), and ABSSSI (15%). Two or more antibiotics were continued upon admission in 916 (27.4%) encounters. Conclusion In our retrospective review of ED antibiotic encounters resulting in admission for at least 2 days, three out of four encounters had at least one antibiotic continued upon admission. This finding highlights the importance of initial appropriate antibiotic selection and suggests stewardship interventions should target EDs as well as inpatient prescribing. Disclosures All authors: No reported disclosures.

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Why is preventing antibiotic resistance so hard? Analysis of failed resistance management

Evolution Medicine and Public Health ◽

10.1093/emph/eoaa020 ◽

2020 ◽

Vol 2020 (1) ◽

pp. 102-108 ◽

Cited By ~ 1

Author(s):

Shiwei Zhou ◽

Camilo Barbosa ◽

Robert J Woods

Keyword(s):

Antibiotic Resistance ◽

Clinical Decision Making ◽

Resistance Management ◽

Clinical Decision ◽

Source Control ◽

Abdominal Infection ◽

Resistance Evolution ◽

Clinical Challenge ◽

Intra Abdominal Infection ◽

Emergence Of Resistance

Abstract We describe the case of a patient with pancreatitis followed by intra-abdominal infection in which source control was not achieved. Antimicrobial therapy led to the emergence of resistance in multiple organisms through multiple population dynamics processes. While the initial insult was not due to infection, subsequent infections with resistant organisms contributed to a poor outcome for the patient. Though resistance evolution was a known risk, it was difficult to predict the next organism that would arise in the setting of antibiotic pressure and its resistance profile. This case illustrates the clinical challenge of antibiotic resistance that current approaches cannot readily prevent. LAY SUMMARY Why is antibiotic resistance management so complex? Distinct evolutionary processes unfold when antibiotic treatment is initiated that lead, separately and together, to the undesired outcome of antibiotic resistance. This clinical case exemplifies some of those processes and highlights the dire need for evolutionary risk assessments to be incorporated into clinical decision making.

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Improved Antimicrobial Host Defense in Mice following Poly-(1,6)-β-d-Glucopyranosyl-(1,3)-β-d-Glucopyranose Glucan Treatment by a Gender-Dependent Immune Mechanism

Clinical and Vaccine Immunology ◽

10.1128/cvi.05202-11 ◽

2011 ◽

Vol 18 (12) ◽

pp. 2043-2049 ◽

Cited By ~ 9

Author(s):

Courtni T. Newsome ◽

Estefany Flores ◽

Alfred Ayala ◽

Stephen Gregory ◽

Jonathan S. Reichner

Keyword(s):

Host Defense ◽

Cecal Ligation ◽

Innate Immune ◽

Source Control ◽

Beta Glucan ◽

Fungal Cell ◽

Abdominal Infection ◽

Female Mice ◽

Beta Glucans ◽

Intra Abdominal Infection

ABSTRACTClinical trials with biological modifiers targeting specific inflammatory mediators associated with severe sepsis have shown no or limited survival benefit. The approach taken in studies reported here was to limit the point source of intra-abdominal infection by potentiating innate immune function, thereby lessening the severity of sepsis and improving survival. Soluble beta-glucans, glucose polymers of the fungal cell wall, have been shown to stimulate innate immune host defense in animal and human studies when administered prior to an infectious challenge. We evaluated the effects of poly-(1,6)-β-d-glucopyranosyl-(1,3)-β-d-glucopyranose glucan (PGG glucan) on overall survival when administered intraperitoneally after the onset of polymicrobial infection by cecal ligation and puncture (CLP). Since gender-dependent differences in host immune response to infection have been reported, male and female mice were prospectively stratified for PGG glucan treatment. Outbred CD-1 mice were administered 10 mg/kg of body weight PGG glucan or the polysaccharide control, dextran, 1 h after CLP. Six hours after CLP, blood samples were obtained for cytokine measurements. Surprisingly, a gender-dependent effect on the response to PGG glucan was revealed. PGG glucan enhanced survival in female mice over a 10-day period, but survival in males was improved for only 24 h. In female mice, PGG glucan reduced interleukin-6 (IL-6) and IL-10 levels and reduced the bacterial burden in the liver. Ovariectomy abrogated the response to PGG glucan. Together, the translational potential of these findings is the indicated use of PGG glucan given locally, rather than intravenously, for improved source control during the management of sepsis. This therapy does not require prophylactic beta-glucan administration.

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413 The Clinical Efficacy of Intra-Operative Peritoneal Fluid Sampling in Abdominal infections

British Journal of Surgery ◽

10.1093/bjs/znab259.517 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

D Mostowfi Zadeh ◽

B Praveen

Keyword(s):

Emergency Surgery ◽

Peritoneal Fluid ◽

Clinical Course ◽

Antibiotic Sensitivity ◽

University Hospital ◽

Abdominal Infection ◽

Intra Abdominal Infection ◽

Abdominal Infections ◽

The Impact ◽

Fluid Sampling

Abstract Aim To uncover the practical efficacy of intra-operative peritoneal fluid sampling and the impact on antibiotic prescription and clinical outcomes in patients undergoing emergency surgery due to intra-abdominal infections. Method Our retrospective study included all patients undergoing emergency surgery for intra-abdominal infections at Southend University Hospital over 6 months (January – July 2019). Data was collected from electronic patient records, case notes and microbiology reports and included the following information: patient age demographics; type of infection; peritoneal fluid sampling indication; samples taken; details of swab culture report including organisms grown and antibiotic sensitivity; clinical course and incidence of subsequent intra-abdominal infection to include readmission and/or further procedures; the type, duration and route of antibiotic prescribed and duration of hospital stay. This audit was approved by the Departmental Audit Lead. Results 441 patients undergoing emergency surgery for intra-abdominal infection were identified. After exclusions, intra-operative peritoneal fluid samples were indicated in 77 patients (mean age 39.4 years). Of these only 3 had samples taken (3.9%). The most common organisms isolated were mixed anaerobes followed by Streptococcus angiosus. The most common antibiotic sensitivity was Metronidazole and Penicillin. One readmission occurred due to an intra-abdominal tubo-ovarian abscess. Conclusions The study shows that the current practice in our hospital regarding intra-operative peritoneal fluid sampling in intra-abdominal infections reflects the present widely held attitudes regarding its reduced practical utility. Abandoning routine sampling had no significant impact on the clinical course and may be more cost-effective. The study may help surgeons reflect on changing perspectives on this traditional practice.

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Intra-abdominal sepsis in the critically ill

10.1093/med/9780199600830.003.0187 ◽

2016 ◽

Author(s):

Jeffrey D. Doyle ◽

John C. Marshall

Keyword(s):

Critically Ill ◽

Anaerobic Bacteria ◽

Abdominal Sepsis ◽

Source Control ◽

Successful Management ◽

Abdominal Infection ◽

Infectious Disease Specialists ◽

Intra Abdominal Infection ◽

Abdominal Infections ◽

Prompt Diagnosis

Intra-abdominal infection encompasses a broad group of infections arising both within the peritoneal cavity and the retroperitoneum. The probable bacteriology reflects patterns of normal and pathological colonization of the gastrointestinal tract. Anaerobic bacteria are found in the distal small bowel and colon. The abdomen is the second most common site of infection leading to sepsis in critically-ill patients. Intra-abdominal infections can be complex to manage and require excellent collaboration between intensivists, diagnostic and interventional radiologists, surgeons, and sometimes gastroenterologists and infectious disease specialists. Prompt diagnosis, appropriate antimicrobial coverage and timely source control are the cornerstones of successful management. The spectrum of pathologic conditions responsible for intra-abdominal infection is broad, although some common biological features facilitate an understanding of their diagnosis and management.

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The Need of Enterococcal Coverage in Severe Intra-Abdominal Infection: Evidence from Animal Study

Journal of Clinical Medicine ◽

10.3390/jcm10051027 ◽

2021 ◽

Vol 10 (5) ◽

pp. 1027

Author(s):

Min Ji Lee ◽

Tae Nyoung Chung ◽

Ye Jin Park B. ◽

Han A. Reum Lee ◽

Jung Ho Lee ◽

...

Keyword(s):

Immune Suppression ◽

Mononuclear Cells ◽

Endotoxin Tolerance ◽

Source Control ◽

Bacterial Clearance ◽

Peripheral Blood Mononuclear ◽

Abdominal Infection ◽

Survival Difference ◽

Enterococcus Spp ◽

Intra Abdominal Infection

Intra-abdominal infection (IAI) is a common and important cause of infectious mortality in intensive care units. Adequate source control and appropriate antimicrobial regimens are key in the management of IAI. In community-acquired IAI, guidelines recommend the use of different antimicrobial regimens according to severity. However, the evidence for this is weak. We investigated the effect of enterococcal coverage in antimicrobial regimens in a severe polymicrobial IAI model. We investigated the effects of imipenem/cilastatin (IMP) and ceftriaxone with metronidazole (CTX+M) in a rat model of severe IAI. We observed the survival rate and bacterial clearance rate. We identified the bacteria in blood culture. We measured lactate, alanine aminotransferase (ALT), creatinine, interleukin (IL)-6, IL-10, and reactive oxygen species (ROS) in the blood. Endotoxin tolerance of peripheral blood mononuclear cells (PBMCs) was also estimated to determine the level of immune suppression. In the severe IAI model, IMP improved survival and bacterial clearance compared to CTX+M. Enterococcus spp. were more frequently isolated in the CTX+M group. IMP also decreased plasma lactate, cytokine, and ROS levels. ALT and creatinine levels were lower in IMP group. In the mild-to-moderate IAI model, however, there was no survival difference between the groups. Immune suppression of PBMCs was observed in IAI model, and it was more prominent in the severe IAI model. Compared to CTX+M, IMP improved the outcome of rats in severe IAI model.

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