Complicated intra-abdominal infections are an important cause of morbidity and are frequently associated with poor clinical prognoses, particularly for patients in high-risk categories.
Source control encompasses all measures undertaken to eliminate the source of infection and control ongoing contamination.
In recent years, the medical community has debated the proper surgical management of complicated intra-abdominal infections.
Acute appendicitis is the most common intra-abdominal condition requiring emergency surgery. However, this preliminary report has demonstrated that complicated appendicitis is also a frequent source of intra-abdominal infection. The laparoscopic appendectomy is a safe and effective means of surgical treatment for addressing complicated intra-abdominal infections, but open surgery still retains many clinical advantages, including a reduced probability of post-operative intra-abdominal abscesses .
In patients with periappendiceal abscesses, the proper course of surgical treatment remains a point of contention in the medical community; however, this contention notwithstanding, the most commonly employed treatment appears to be drainage with subsequent appendectomy .
CIAO Study data indicate that the open approach was used in 54% of complicated appendicitis cases while the laparoscopic approach was favored and performed on 40.8% of complicated appendicitis patients. Eight patients underwent percutaneous drainage and interval appendectomies.
The laparoscopic versus open cholecystectomy debate has been extensively investigated in recent years. In the CIAO Study, the open cholecystectomy was the most frequently performed procedure for addressing cholecystitis. 50.4% and 31.5% of cholecystitis patients underwent the open and laparoscopic procedures, respectively.
The optimal surgical management of colonic diverticular disease complicated by peritonitis remains a controversial issue in the medical community.
Hartmann’s resection has historically been considered the procedure of choice for patients with generalized peritonitis and continues to be a safe and reliable technique for performing an emergency colectomy in the event of perforated diverticulitis, particularly in elderly patients with multiple co-morbidities [7–9].
More recently, some reports have suggested that primary resection and anastomosis is the preferred approach to addressing diverticulitis, even in the presence of diffuse peritonitis [10–13].
According to the preliminary CIAO Study data, the Hartmann resection was the most frequently employed procedure for treating complicated diverticulitis. 49.3% of patients underwent this surgical resection. Among the 35 enrolled patients who had undergone a Hartmann resection, 23 patients presented with generalized peritonitis and 12 presented with localized peritonitis or abscesses. 22.5% of patients underwent colo-rectal resection to address complicated diverticulitis.
The significance of microbiological workups of infected peritoneal fluid taken from community-acquired intra-abdominal infections has been debated in recent years.
Since the causative pathogens are often accurately predicted in low-risk patients with community-acquired IAIs, some researchers believe bacteriological diagnosis to be superfluous for these patients. The lack of clinical relevance of many bacteriological cultures has been readily documented, especially in appendicitis cases in which the etiological agents causing the peritonitis are easily predicted . Other researchers assert that bacteriological diagnosis is still important for low-risk patients with community-acquired IAIs primarily because it may be of value in detecting epidemiological changes in the resistance patterns of pathogens associated with these infections and in better assessing follow-up antibiotic therapy. In higher risk patients with community-acquired IAIs and healthcare-associated IAIs, cultures from the site of infection should always be always obtained.
According to the preliminary CIAO Study data, intraperitoneal specimens were collected from the 64.2% of enrolled patients; these samples were obtained from 60.2% of patients with community-acquired intra-abdominal infections and 83.9% of patients with healthcare-associated intra-abdominal infections.
Routine susceptibility testing for anaerobic organisms continues to prove difficult for many laboratories given a variety of economic and logistical constraints; most clinical laboratories do not routinely determine the species of the organism or test the susceptibilities of anaerobic isolates .
CIAO Study data indicate that 44.7% of patients were tested for the presence of aerobic microorganisms.
The major pathogens involved in community-acquired intra-abdominal infections are Enterobacteriaceae, Streptococcus species, and certain anaerobes (particularly B. fragilis). Compared to community-acquired infections, healthcare-associated infections typically involved a broader spectrum of microorganisms, encompassing ESBL-producing Enterobacteriaceae, Enterococcus, Pseudomonas, and Candida species in addition to the Enterobacteriaceae, Streptococcus species, and anaerobes typically observed in community-acquired IAIs.
The threat of antimicrobial resistance has become a major challenge in the management of intra-abdominal infections.
The main resistance threat is posed by ESBL-producing Enterobacteriaceae, which are frequently found in community-acquired infections.
According to the study’s preliminary findings, ESBL producers were the most prevalent and commonly identified drug-resistant microorganism.
Two isolates of Klebsiella pneumoniae appeared to be resistant to Carbapenems. These particular infections were acquired in the intensive care unit.
The rate of Pseudomonas aeruginosa among aerobic isolates was 4.6%. There was no statistically significant difference in the Pseudomonas appearance rate between community-acquired and healthcare-associated IAIs.
Enterococci (E. faecalis and E. faecium) were identified in 14.5% of all aerobic isolates.
Although Enterococci were also present in community-acquired infections, they were far more prevalent in healthcare-associated infections.
Data currently available in mainstream literature regarding the infectious trends of Candida species are rather contradictory .
In the first half of the CIAO Study, 45 Candida isolates (5.7%) were observed among a total of 825 isolates. Candida prevalence was significantly higher in the healthcare-associated IAI group than it was in the community-acquired IAI group.
Of the 912 patients enrolled in the study, there were 58 deaths (6.4%).
According to univariate statistical analysis of the data, critical clinical condition of the patient upon hospital admission (defined by severe sepsis and septic shock) as well as healthcare-associated infections, non-appendicular origin, generalized peritonitis, and serious comorbidities such as malignancy and severe cardiovascular disease were all significant risk factors for patient mortality. WBCs greater than 12,000 or less than 4,000 and core body temperatures greater than 38°C or less than 36°C by the third post-operative day were statistically significant indicators of patient mortality.