Factors of unfavorable outcome of generalized peritonitis

Aim. To analyze clinical and bacteriologic factors associated with the occurrence of septic shock and mortality in patients with secondarily generalized peritonitis.Materials and methods. The analysis of the results of the examination and treatment of 180 patients with generalized peritonitis was carried out. Patients were divided into two groups: the first group of 74 patients (41.1%) who had septic shock and the second group of 106 patients (58.9%) without a record of septic shock. Further, subgroups of patients with community-acquired and postoperative generalized peritonitis were identified in a ratio of 112/68.Results and discussion. Mortality among patients with community-acquired peritonitis was 21% and among patients with postoperative peritonitis - 16%. 42 (37%) patients with community-acquired peritonitis developed septic shock compared with 32 (47%) cases of shock among patients with postoperative peritonitis. Patients who developed septic shock were significantly older than patients without septic shock in both subgroups. In both types of generalized peritonitis, anaerobes are significantly associated with septic shock.Conclusions. It was revealed that age over 65 years, two or more microorganisms of the peritoneal fluid, or anaerobes were independent risk factors for the development of septic shock. Peritoneal exudate yeast and enterococci were associated with septic shock in a subgroup of patients with community-acquired peritonitis. Yeast was associated with high mortality in postoperative peritonitis.

Micafungin population PK analysis in plasma and peritoneal fluid in septic patients with intra-abdominal infections: a prospective cohort study

Objectives: To describe the pharmacokinetics (PK) of micafungin in plasma and peritoneal fluid in septic patients with intra-abdominal infections. Methods: Twelve patients with secondary peritonitis in septic shock receiving 100 mg micafungin once daily were included. Total micafungin plasma and peritoneal fluid were subject to a population pharmacokinetic analysis using Pmetrics®. Monte Carlo simulations were performed considering total AUC0-24h/MIC ratios in plasma. Results: Micafungin concentrations in both plasma and peritoneal exudate were best described by a three-compartmental PK model with the fat free mass (FFM) as a covariate of clearance (CL) and volume of the central compartment (Vc). The mean parameter estimates (standard deviation, SD) were 1.18 (0.40) L/h for CL and 12.85 (4.78) L for Vc. The mean peritoneal exudate/plasma ratio (SD) of micafungin was 25% (5%) on day 1 and 40% (8%) between day 3-5. Dosing simulations supported the use of standard 100 mg daily dosing for C. albicans (FFM < 60 kg), C. glabrata (FFM < 50 kg) and C. tropicalis (FFM < 30 kg) on the second day of therapy. Conclusions: There is a moderate penetration of micafungin into peritoneal cavity (25 to 40%). For empirical treatment, a dose escalation of at least a loading dose of 150 mg depending on the FFM of patients and Candida species is suggested to be effective from the first day of therapy.

Infectious Agents Identified by Real-Time PCR, Serology and Bacteriology in Blood and Peritoneal Exudate Samples of Cows Affected by Parietal Fibrinous Peritonitis after Caesarean Section

The aim of this study was to identify the pathogens potentially involved in parietal fibrinous peritonitis (PFP). PFP is a complication of laparotomy in cattle, characterized by an accumulation of exudate inside a fibrinous capsule. We have studied 72 cases of PFP in Belgian blue cows, confirmed by a standard diagnostic protocol. Blood was collected to evaluate the presence of antibodies for Mycoplasma bovis(M. bovis), Coxiella burnetii(C. burnetii) and Bovine Herpesvirus 4(BoHV4) by enzyme-linked immunosorbent assays. Peritoneal exudate was obtained from the PFP cavity to perform bacteriological culture, and to identify the DNA of M. bovis, C. burnetii and BoHV4 using real time polymerase chain reaction (qPCR). Bacteriological culture was positive in most peritoneal samples (59/72); Trueperella pyogenes (T. pyogenes) (51/72) and Escherichia coli (E. coli) (20/72) were the most frequently identified. For BoHV4, the majority of cows showed positive serology and qPCR (56/72 and 49/72, respectively). Contrariwise, M. bovis (17/72 and 6/72, respectively) and C. burnetii (15/72 and 6/72, respectively) were less frequently detected (p < 0.0001). Our study proves that PFP can no longer be qualified as a sterile inflammation. Moreover, we herein describe the first identification of BoHV4 and C. burnetii in cows affected by PFP.

RESEARCH ON THE EFFICIENCY OF THE USE OF THE SORBENT COMBINATION AND ANTISEPTICS IN THE COMPLEX TREATMENT OF PERITONITIS

Summary. The aim of the study was to investigate the effectiveness of using a combination of antiseptic and sorbent for decontamination of the abdominal cavity in patients with diffuse peritonitis. The study of isolated peritoneal exudate obtained in patients with diffuse appendicular peritonitis. The exudate determined the species composition and population level of the micro flora before and during the 24-hour incubation without sorbent and antiseptic and their combined use. Bench studies have shown that peritoneal exudate of patients with acute appendicitis, complicated by peritonitis, is contaminated with microorganisms belonging to different taxonomic groups. The anaerobic-aerobic associations of bacterroids, Escherichia coli and fecal enterococcus were dominant among the detected microorganisms. With in 24 hours of incubation, the population level of exudate micro flora increased, which was incubated without sorbent and antiseptic. In a series of studies where the exudate was incubated with the sorbent, a significant decrease in the population level of the micro flora was observed. The combination of sorbent and antiseptic retained its detoxifying and decontaminating properties with respect to toxic factors and pathogens of peritoneal exudate throughout the incubation period, however, the most pronounced properties were observed during the first 12 hours of incubation. Their combined use has been shown to reduce bacterial contamination of peritoneal exudate and reduce the risk of postoperative complications.

FUNCTIONAL PROPERTIES OF BLOOD NEUTROPHILS AND PERITONEAL EXUDATE IN PATIENTS WITH PERITONITIS

The aim of the study is to investigate the functional properties of neutrophils in the blood and peritoneal exudate in patients with peritonitis. Materials and methods. The metabolic activity of neutrophils determined in patients with peritonitis and in patients of the control groups in the blood, peritoneal exudate and effusion of the abdominal wall on the 1–2 day of the postoperative period in the Sp and St test with nitro blue tetrazolium (NBT), as well as reserve indicator (RI) of metabolic activity. We studied the percentage of active neutrophils in the phagocytosis –PhI ( index) and the number of absorbed Candida albicans particles on average by one neutrophil –PhN(number). Results and their discussion.The peculiarities of the cellular factors of local protection decreased metabolic activity of neutrophils in the abdominal cavity in the Sp NBT test compared to blood neutrophils and an increased reserve during stimulation. For the comparisons which included the activity of neutrophils abdominal contents in patients with peritonitis versus in control established that neutrophils in the abdominal cavity with peritonitis have a reduced intensity of phagocytosis. Patients with pancreatic peritonitis have inverse correlations between the amount of NBT-positive blood NG in the SP NBT test and IR of blood NG and between the amount of NBT-positive blood NG in the Sp NST test and PhI of blood NG, while patients with abdominal peritonitis do not have correlations between indicators of innate defense of the body. Conclusions. Peritonitis was associated with functional disorders of NG. The leading areas of disorders are significant activation of metabolic processes of NG and inhibition of the phagocytic function of NG blood and peritoneal exudate. Patients with pancreatic peritonitis had inverse correlations between the indicators of the innate defense of the body, while patients with abdominal peritonitis did not have correlations.

INDICATIONS FOR THE PROGRAMMED REMEDIAL RELAPAROTOMIES IN DIFFUSE PERITONITIS

INTRODUCTION. Diffuse peritonitis remains a topical problem of modern medicine and is still associated with high mortality. The OBJECTIVE of this work was to develop an objective and easy-to-perform method for determining the indications for programmed relaparotomy in patients with diffuse peritonitis on the basis of determining the aggressiveness of its course.MATERIAL AND METHODS. The work was based on the results of treatment of 100 patients with diffuse peritonitis. Depending on the pH of the exudate of the peritoneal cavity, the patients were divided into 2 groups. The first group consisted of patients with pH value of peritoneal exudate more than 6.2 (75 patients), and the second group consisted of patients with pH value of peritoneal exudate 6.2 and less (25 patients).RESULTS. As a result of the treatment in group I, the mortality rate was 12.0 %. In group II, the mortality rate was 56.0 %. The difference was statistically significant (p<0.001). In group I, 4 patients underwent relaparotomy (5.3 %), and in group II, 17 patients underwent relaparotomy (68.0 %). The difference was statistically significant (p<0.001).CONCLUSION. We concluded that at pH value of exudate 6.2 or less and the absence of obvious clinical improvement, the patient had been showed to performance the programmed remedial relaparotomy no later than 48 hours from the first operation.The authors declare no conflict of interest.The authors confirm that they respect the rights of the people participated in the study, including obtaining informed consent when it is necessary, and the rules of treatment of animals when they are used in the study. Author Guidelines contains the detailed information.

Serum and peritoneal exudate concentrations after high doses of β-lactams in critically ill patients with severe intra-abdominal infections: an observational prospective study

Background Critically ill patients with severe intra-abdominal infections (IAIs) requiring surgery may undergo several pharmacokinetic (PK) alterations that can lead to β-lactam underdosage. Objectives To measure serum and peritoneal exudate concentrations of β-lactams after high doses and optimal administration schemes. Methods This observational prospective study included critically ill patients with suspicion of IAI who required surgery and a β-lactam antibiotic as empirical therapy. Serum and peritoneal exudate concentrations were measured during surgery and after a 24 h steady-state period. The PK/pharmacodynamic (PD) target was to obtain serum β-lactam concentrations of 100% fT&gt;4×MIC based on a worst-case scenario (based on the EUCAST highest epidemiological cut-off values) before bacterial documentation (a priori) and redefined following determination of the MIC for the isolated bacteria (a posteriori). Registered with ClinicalTrials.gov (NCT03310606). Results Forty-eight patients were included with a median (IQR) age of 64 (53–74) years and a SAPS II of 40 (32–65). The main diagnosis was secondary nosocomial peritonitis. Piperacillin/tazobactam was the most administered β-lactam antibiotic (75%). The serum/peritoneal piperacillin/tazobactam ratio was 0.88 (0.64–0.97) after a 24 h steady-state period. Prior to bacterial documentation, 16 patients (33.3%) achieved the a priori PK/PD target. The identification of microorganisms was available for 34 patients (71%). Based on the MIC for isolated bacteria, 78% of the patients achieved the serum PK/PD target. Conclusions In severe IAIs, high doses of β-lactams ensured 100% fT&gt;4×MIC in the serum for 78% of critically ill patients with severe IAIs within the first 24 h. In order to define optimal β-lactam dosing, the PK/PD target should take into account the tissue penetration and local ecology.