Skip to content


Open Access

Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study)

  • Massimo Sartelli1Email author,
  • Fikri M. Abu-Zidan2,
  • Fausto Catena3,
  • Ewen A. Griffiths4,
  • Salomone Di Saverio5,
  • Raul Coimbra6,
  • Carlos A. Ordoñez7,
  • Ari Leppaniemi8,
  • Gustavo P. Fraga9,
  • Federico Coccolini10,
  • Ferdinando Agresta11,
  • Asrhaf Abbas12,
  • Saleh Abdel Kader13,
  • John Agboola14,
  • Adamu Amhed15,
  • Adesina Ajibade16,
  • Seckin Akkucuk17,
  • Bandar Alharthi18,
  • Dimitrios Anyfantakis19,
  • Goran Augustin20,
  • Gianluca Baiocchi21,
  • Miklosh Bala22,
  • Oussama Baraket23,
  • Savas Bayrak24,
  • Giovanni Bellanova25,
  • Marcelo A. Beltràn26,
  • Roberto Bini27,
  • Matthew Boal4,
  • Andrey V. Borodach28,
  • Konstantinos Bouliaris29,
  • Frederic Branger30,
  • Daniele Brunelli31,
  • Marco Catani32,
  • Asri Che Jusoh33,
  • Alain Chichom-Mefire34,
  • Gianfranco Cocorullo35,
  • Elif Colak36,
  • David Costa37,
  • Silvia Costa38,
  • Yunfeng Cui39,
  • Geanina Loredana Curca40,
  • Terry Curry6,
  • Koray Das41,
  • Samir Delibegovic42,
  • Zaza Demetrashvili43,
  • Isidoro Di Carlo44,
  • Nadezda Drozdova45,
  • Tamer El Zalabany46,
  • Mushira Abdulaziz Enani47,
  • Mario Faro48,
  • Mahir Gachabayov49,
  • Teresa Giménez Maurel50,
  • Georgios Gkiokas51,
  • Carlos Augusto Gomes52,
  • Ricardo Alessandro Teixeira Gonsaga53,
  • Gianluca Guercioni54,
  • Ali Guner55,
  • Sanjay Gupta56,
  • Sandra Gutierrez57,
  • Martin Hutan58,
  • Orestis Ioannidis59,
  • Arda Isik60,
  • Yoshimitsu Izawa61,
  • Sumita A. Jain62,
  • Mantas Jokubauskas63,
  • Aleksandar Karamarkovic64,
  • Saila Kauhanen65,
  • Robin Kaushik56,
  • Jakub Kenig66,
  • Vladimir Khokha67,
  • Jae Il Kim68,
  • Victor Kong69,
  • Renol Koshy44,
  • Avidyl Krasniqi70,
  • Ashok Kshirsagar71,
  • Zygimantas Kuliesius72,
  • Konstantinos Lasithiotakis73,
  • Pedro Leão74,
  • Jae Gil Lee75,
  • Miguel Leon76,
  • Aintzane Lizarazu Pérez77,
  • Varut Lohsiriwat78,
  • Eudaldo López-Tomassetti Fernandez79,
  • Eftychios Lostoridis80,
  • Raghuveer Mn81,
  • Piotr Major82,
  • Athanasios Marinis83,
  • Daniele Marrelli84,
  • Aleix Martinez-Perez85,
  • Sanjay Marwah86,
  • Michael McFarlane87,
  • Renato Bessa Melo88,
  • Cristian Mesina89,
  • Nick Michalopoulos90,
  • Radu Moldovanu91,
  • Ouadii Mouaqit92,
  • Akutu Munyika93,
  • Ionut Negoi94,
  • Ioannis Nikolopoulos95,
  • Gabriela Elisa Nita10,
  • Iyiade Olaoye96,
  • Abdelkarim Omari97,
  • Paola Rodríguez Ossa7,
  • Zeynep Ozkan98,
  • Ramakrishnapillai Padmakumar99,
  • Francesco Pata100,
  • Gerson Alves Pereira Junior101,
  • Jorge Pereira102,
  • Tadeja Pintar103,
  • Konstantinos Pouggouras80,
  • Vinod Prabhu104,
  • Stefano Rausei105,
  • Miran Rems106,
  • Daniel Rios-Cruz107,
  • Boris Sakakushev108,
  • Maria Luisa Sánchez de Molina109,
  • Charampolos Seretis110,
  • Vishal Shelat111,
  • Romeo Lages Simões9,
  • Giovanni Sinibaldi112,
  • Matej Skrovina113,
  • Dmitry Smirnov114,
  • Charalampos Spyropoulos115,
  • Jaan Tepp116,
  • Tugan Tezcaner117,
  • Matti Tolonen8,
  • Myftar Torba118,
  • Jan Ulrych119,
  • Mustafa Yener Uzunoglu120,
  • David van Dellen121,
  • Gabrielle H. van Ramshorst122,
  • Giorgio Vasquez123,
  • Aurélien Venara30,
  • Andras Vereczkei124,
  • Nereo Vettoretto125,
  • Nutu Vlad126,
  • Sanjay Kumar Yadav127,
  • Tonguç Utku Yilmaz128,
  • Kuo-Ching Yuan129,
  • Sanoop Koshy Zachariah130,
  • Maurice Zida131,
  • Justas Zilinskas63 and
  • Luca Ansaloni10
World Journal of Emergency Surgery201510:61

Received: 17 November 2015

Accepted: 10 December 2015

Published: 16 December 2015



To validate a new practical Sepsis Severity Score for patients with complicated intra-abdominal infections (cIAIs) including the clinical conditions at the admission (severe sepsis/septic shock), the origin of the cIAIs, the delay in source control, the setting of acquisition and any risk factors such as age and immunosuppression.


The WISS study (WSES cIAIs Score Study) is a multicenter observational study underwent in 132 medical institutions worldwide during a four-month study period (October 2014-February 2015). Four thousand five hundred thirty-three patients with a mean age of 51.2 years (range 18–99) were enrolled in the WISS study.


Univariate analysis has shown that all factors that were previously included in the WSES Sepsis Severity Score were highly statistically significant between those who died and those who survived (p < 0.0001). The multivariate logistic regression model was highly significant (p < 0.0001, R2 = 0.54) and showed that all these factors were independent in predicting mortality of sepsis. Receiver Operator Curve has shown that the WSES Severity Sepsis Score had an excellent prediction for mortality. A score above 5.5 was the best predictor of mortality having a sensitivity of 89.2 %, a specificity of 83.5 % and a positive likelihood ratio of 5.4.


WSES Sepsis Severity Score for patients with complicated Intra-abdominal infections can be used on global level. It has shown high sensitivity, specificity, and likelihood ratio that may help us in making clinical decisions.


Intra-abdominalInfectionsSepsisSeptic shock


Intra-abdominal infections (IAIs) include several different pathological conditions [1] and are usually classified into uncomplicated and complicated. In complicated IAIs (cIAIs), the infectious process extends beyond the organ, and causes either localized peritonitis or diffuse peritonitis. The treatment of patients with complicated intra-abdominal infections involves both source control and antibiotic therapy. Complicated IAIs are an important cause of morbidity and may be associated with poor prognosis. However the term “complicated intra-abdominal infections” describes a wide heterogeneity of patient populations, making it difficult to suggest a general treatment regimen and stressing the need of an individualized approach to decision making.

Early prognostic evaluation of complicated intra-abdominal infections is crucial to assess the severity and decide the aggressiveness of treatment. Many factors influencing the prognosis of patients with cIAIs have been described, including advanced age, poor nutrition, pre-existing diseases, immunosuppression, extended peritonitis, occurrence of septic shock, poor source control, organ failures, prolonged hospitalization before therapy, and infection with nosocomial pathogens [210].

Recently the World Society of Emergency Surgery (WSES) designed a global prospective observational study (CIAOW Study) [11, 12]. All the risk factors for occurrence of death during hospitalization were evaluated and then discussed with an international panel of experts. The most significant variables, adjusted to clinical criteria, were used to create a severity score for patients with cIAIs including the clinical conditions at admission (severe sepsis/septic shock), the origin of the cIAIs, the delay in source control, the setting of acquisition and any risk factors such as age and immunosuppression (Appendix).

There may be different causes of sepsis, health care standards, and differences in underlying health status, economical differences that make prediction of sepsis on global level difficult. The WSES addressed this issue in the present study which aims to validate a previous score on a global level.


Ethical statement

The study met the standards outlined in the Declaration of Helsinki and Good Epidemiological Practices. This study did not change or modify the laboratory or clinical practices of each centre and differences of practices were kept as they are. The data collection was anonymous and identifiable patient information was not submitted.

Individual researchers were responsible for complying with local ethical standards and hospital registration of the study.

Study population

This multicenter observational study was run in 132 medical institutions from 54 countries worldwide during a four-month period (October 2014-February 2015). Inclusion criteria were patients older than 18 years with complicated intra-abdominal sepsis (cIAIs) who had surgical management or interventional radiological drainage. cIAIs was defined as an infectious process that proceeded beyond the organ, and caused either localized peritonitis/abscess or diffuse peritonitis [13]. Patients who were younger than 18 years, or those who had pancreatitis, or primary peritonitis were excluded from the study. Severe sepsis was defined as sepsis-induced tissue hypoperfusion or organ dysfunction (any of the following thought to be due to the infection): hypotension (<90/60 or MAP < 65), lactate above upper limits laboratory normal, Urine output < 0.5 mL/kg/h for more than 2 h despite adequate fluid resuscitation, Creatinine > 2.0 mg/dL (176.8 μmol/L), Bilirubin > 2 mg/dL (34.2 μmol/L), Platelet count < 100,000 μL, Coagulopathy (international normalized ratio > 1.5), Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source. Septic shock was defined as severe sepsis associated with refractory hypotension (BP < 90/60) despite adequate fluid resuscitation [14].

WSES Sepsis Severity Score for patients with complicated Intra-abdominal infections is shown in Appendix .

Data monitoring and collection

The study was monitored by the coordination center, which investigated and verified missing or unclear data submitted to the central database. This study was performed under the direct supervision of the Board of Directors of WSES. In each centre, the coordinator collected and compiled data in an online case report system. Data were entered directly through a web-based computerized database. Data were entered either by a drop menu for categorical data like the source of infection or numbers for continuous variables such as age. Data collected included demographic data of the patient and disease characteristics, demographical data, type of infection (community- or healthcare-acquired), severity criteria and origin of infection and surgical procedures performed.

Statistical analysis

Sepsis status was coded as ordinal data for testing the logistic regression (not for scoring) as follows: no sepsis = 0, sepsis = 2, severe sepsis = 3, septic shock = 4). The source of sepsis was analysed as categorical data in the logistic regression, and the age as continuous data, while healthcare associated infection, delay in management, and immunosuppression as binomial data. The variables used in this scoring system in the patients who survived and those who died were compared using univariate analysis. This included Fisher’s exact test or Pearson Chi-Square as appropriate for categorical data and Mann–Whitney U-test for continuous or ordinal data. Significant factors were then entered into a direct logistic regression model. A p value of ≤ 0.05 was considered significant. Data were analyzed with PASW Statistics 21, SPSS Inc, USA.


Four thousand six hundred fifty-two cases were collected in the online case report system. One hundred twenty-nine cases did not meet the inclusion criteria. Four thousand five hundred thirty-three patients with a mean age of 51.2 years (range 18–99) were enrolled in the WISS study. One thousand nine hundred thirty-five patients (42.7 %) were women and 2598 (57.3 %) were men.

Among these patients, 3966 (87.5 %) were affected by community-acquired IAIs while the remaining 567 (12.5 %) suffered from healthcare-associated infections. One thousand six hundred twenty-seven patients (35.9 %) were affected by generalized peritonitis while 2906 (64.1 %) suffered from localized peritonitis or abscesses. Seven hundred ninety-one patients (17.4 %) were admitted in critical condition (severe sepsis/septic shock). The various sources of infection are outlined in Table 1. The most frequent source of infection was acute appendicitis; 1553 cases (34.2 %) involved complicated appendicitis.
Table 1

Source of infection in 4553 patients from 132 hospitals worldwide (15 October 2014–15 February 2015)

Source of infection

Number (%)


1553 (34.2 %)


837 (18.5 %)


387 (8.5 %)

Colonic non diverticular perforation

269 (5.9 %)

Gastro-duodenal perforations

498 (11 %)


234 (5.2 %)

Small bowel perforation

243 (5.4 %)


348 (7.7 %)


50 (1.1 %)

Post traumatic perforation

114 (2.5 %)




4553 (100 %)

PID pelvic inflammatory disease

The overall mortality rate was 9.2 % (416/4533).

Table 2 shows the univariate analysis comparing patients with complicated intra-abdominal infection who survived and those who died. The analysis shows that all factors included in the Sepsis Severity Score were highly significantly different between those who died and those who survived (p < 0.0001 in all variables). Accordingly all factors were entered into a direct logistic regression model (Table 3). The direct logistic regression model was highly significant (p < 0.0001, R2 = 0.54) and showed that all factors included in the Sepsis Severity Score were significant independent predictors of mortality. Accordingly the ability of the score to predict mortality was tested by a direct logistic regression which is shown in Table 4. Again, this model using only the sepsis severity score was highly significant (p < 0.0001, R2 = 0.5). The odds of death increased by 0.78 by an increase on one score which is remarkable.
Table 2

Univariate analysis of patients with complicated intra-abdominal infection comparing patients who survived (n = 4117) and patient who died (n = 416)


Survided (%) n = 4117

Died (%) n = 416

p value

Sepsis status



 No sepsis

1914 (46.5 %)

23 (5.5 %)


1725 (41.9 %)

80 (19.2 %)

 Severe sepsis

404 (9.8 %)

157 (37.7 %)

 Septic shock

74 (1.8 %)

156 (37.5 %)

Healthcare associated infection

433 (10.5 %)

134 (32.2 %)


Source of infection




1536 (37.3 %)

17 (4.1 %)


809 (19.7 %)

28 (6.7 %)

 Colonic non diverticular perforation

204 (5 %)

65 (15.6 %)


203 (4.9 %)

31 (7.5 %)

 Gastro-duodenal perforation

431 (10.5 %)

67 (16.2 %)


50 (1.2 %)

0 (0)


415 (10.1 %)

86 (20.7 %)

 Small bowel perforation

174 (4.2 %)

69 (16.6 %)


104 (2.5 %)

10 (2.4 %)


259 (6.3 %)

53 (12.7 %)

Delay in source control

2015 (48.9 %)

341 (82 %)


Median age years (range)

48 (18–97)

79 (18–99)



292 (7.1)

120 (28.8 %)


Sepsis severity score

3 (0–17)

10 (0–17)


Data presented as median range or number percentage as appropriate

PID pelvic inflammatory disease

p value = Fisher’s exact test, Pearson Chi-Square, or Mann Whitney U test as appropriate

Table 3

Direct logistic regression model with factors affecting mortality of patients complicated intra-abdominal infection, global study of 132 centres, (n = 4553)

Score variable



Wald test

P value


OR 95 % C.I.



Sepsis status








Setting of infection acquisition








Source of infectiona





 Colonic non-diverticulical perforation








 Diverticulitis diffuse peritonitis








 Postoperative diffuse peritonitis








 Remaining sources








Delay in management































OR odds ratio

aCompared with small bowel perforation

Table 4

Direct logistic regression model showing the ability of WSES Sepsis Severity Score in predicting mortality of patients complicated intra-abdominal infection, global study of 132 centres, (n = 4553)





P value


OR 95 % C.I.


















OR odds ratio

Figure 1 shows that WSES Sepsis Severity Score had a very good ability of distinguishing those who survived from those who died. The overall mortality rate was 9.2 % (416/4533). This was 0.63 % for those who had a score of 0–3, 6.3 % for those who had a score of 4–6, and 41.7 % for those who had a score of ≥ 7. The receiver operating characteristic curve showed that the best cutoff point for predicting mortality was a Sepsis Severity Score. 5.5 was the best predictor of mortality having a sensitivity of 89.2 %, a specificity of 83.5 % and a positive likelihood ratio of 5.4 (Fig. 2).
Figure 1
Fig. 1

Distribution of the percentile WSES Sepsis Severity Score of complicated intra-abdominal infection patients for those who survived (solid line) (n = 4117) and those who died (interrupted line) (n = 416)

Figure 2
Fig. 2

Receiver operating characteristic curve for the best WSES Sepsis Severity Score that predicted mortality in patients having complicated intra-abdominal infection, global study of 132 centres, (n = 4553)


Complicated intra-abdominal infections remain an important source of patient morbidity and may be frequently associated with poor clinical prognosis. Treatment of patients with cIAIs, has been usually described to achieve satisfactory results if adequate management is established [15]. However, results from published clinical trials may not be representative of the true morbidity and mortality rates of such severe infections. First of all, patients who have perforated appendicitis are usually over-represented in clinical trials. Furthermore patients with intra-abdominal infection enrolled in clinical trials have often an increased likelihood of cure and survival. In fact the trial eligibility criteria usually restrict the inclusion of patients with co-morbid diseases that would increase the death rate of patients with intra-abdominal infections [16]. In the WISS study we enrolled all the patients older than 18 years old with complicated intra-abdominal infections in the study-period and the overall mortality rate was 9.2 % (416/4533). Stratification of the patient’s risk is essential in order to optimize the treatment plan. Patients with intra-abdominal infections are generally classified into low risk and high risk. “High risk” is generally intended to describe patients with a high risk for treatment failure and mortality. In high risk patients the increased mortality associated with inappropriate management cannot be reversed by subsequent modifications. Therefore early prognostic evaluation of complicated intra-abdominal infections is important to assess the severity and decide the aggressiveness of treatment.

Scoring systems can be roughly divided into two groups: disease-independent scores for evaluation of serious patients requiring care in the intensive care unit (ICU) such as APACHE II and Simplified Acute Physiology Score (SAPS II) and peritonitis-specific scores such as Mannheim Peritonitis Index (MPI) [17].

Although considered a good marker, APACHE II value in peritonitis has been questioned because of the difficulty of the APACHE II to evaluate interventions despite the fact that interventions might significantly alter many of the physiological variables. Moreover it requires appropriate software to be calculated [18].

The MPI is specific for peritonitis and easy to calculate. MPI was designed by Wacha and Linder in 1983 [19]. It was based on a retrospective analysis of data from 1253 patients with peritonitis. Among 20 possible risk factors, only 8 proved to be of prognostic relevance and were entered into the Mannheim Peritonitis Index, classified according to their predictive power. After 30 years, identifying a new clinical score to assess the severity the cIAIS would be clinically relevant in order to modulate the aggressiveness of treatment according the type of infection and the clinical characteristics of the patients.

WSES Sepsis Severity Score is a new practical clinical severity score for patients with complicated intra-abdominal infections. It is specific for cIAIs and easy to calculate, even during surgery. It may be relevant in order to modulate the aggressiveness of treatment particularly in higher risk patients.

The score is illustrated in Appendix. The statistical analysis shows that the sepsis severity score has a very good ability of distinguishing those who survived from those who died. The overall mortality was 0.63 % for those who had a score of 0–3, 6.3 % for those who had a score of 4–6, 41.7 % for those who had a score of ≥ 7. In patients who had a score of ≥ 9 the mortality rate was 55.5 %, those who had a score of ≥ 11 the mortality rate was 68.2 % and those who had a score ≥ 13 the mortality rate was 80.9 %.


Given the sweeping geographical distribution of the participating medical centers, WSES Sepsis Severity Score for patients with complicated Intra-abdominal infections can be used on global level. It has shown high sensitivity, specificity, and likelihood ratio that may help us in making clinical decisions.


Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

Department of Surgery, Macerata Hospital, Macerata, Italy
Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
General and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
Department of Surgery, Maggiore Hospital, Bologna, Italy
Department of Surgery, UC San Diego Medical Center, San Diego, USA
Fundación Valle del Lili, Universidad del Valle, Cali, Colombia
Abdominal Center, University Hospital Meilahti, Helsinki, Finland
Division of Trauma Surgery, Hospital de Clinicas, School of Medical Sciences, University of Campinas, Campinas, Brazil
General and Emergency Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy
General Surgery, ULSS19 del Veneto, Adria, Italy
Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
Department of General Surgery, Al Ain Hospital, Al-Ain City, United Arab Emirates
Department of Surgery, Kwara State General Hospital, Ilorin, Nigeria
Department of Surgery, Ahmadu Bello University Teaching Hospital Zaria, Kaduna, Nigeria
Department of Surgery, LAUTECH Teaching Hospital, Osogbo, Nigeria
Department of General Surgery, Training and Research Hospital of Mustafa Kemal University, Hatay, Turkey
Depatment of Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
Primary Health Care Centre of Kissamos, Chania, Greece
Department of Surgery, University Hospital Center, Zagreb, Croatia
Clinical and Experimental Surgery, Brescia Civil Hospital, Brescia, Italy
Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
Department of Surgery, Bizerte Hospital, Bizerte, Tunisia
Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
Surgical II Division, S. Chiara Hospital, Trento, Italy
Department of General Surgery, Hospital San Juan de Dios de La Serena, La Serena, Chile
Department of General and Emergency Surgery, SG Bosco Hospital, Turin, Italy
Emergency Surgery Department, 1st Municipal Hospital, Novosibirsk State Medical University, Novosibirsk, Russian Federation
Department of Surgery, University Hospital of Larissa, Larissa, Greece
Visceral Surgery, CHU, Angers, France
Chirurgia Generale, Ospedale di Città di Castello, Città di Castello, Italy
Department of Emergency Surgery, Umberto I Hospital, “La Sapienza” University, Rome, Italy
Department of Surgery, Kuala Krai Hospital, Kelantan, Malaysia
Department of Surgery, Regional Hospital, Limbe, Cameroon
General and Emergency Surgery, Policlinico Paolo Giaccone, Palermo, Italy
Department of General Surgery, Samsun Education and Research Hospital, Samsun, Turkey
Department of General and Digestive Tract Surgery, Alicante University General Hospital, Alicante, Spain
Department of Surgery, CHVNG/E, EPE, Vila Nova de Gaia, Portugal
Department of Surgery, Tianjin Nankai Hospital, Tianjin, China
Department of General Surgery, Emergency Municipal Hospital Pascani, Pascani, Romania
Department of Surgery, Numune Training and Research Hospital, Adana, Turkey
Department of Surgery, University Clinical Center, Tuzla, Bosnia and Herzegovina
Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
Department of Surgery, Hamad General Hospital, Doha, Qatar
Department of Surgery, Riga East Clinical University Hospital, Riga, Latvia
Department of Surgery, Bahrain Defence Force Hospital, Manama, Bahrain
King Fahad Medical City, Riyadh, Saudi Arabia
Division of General and Emergency Surgery, Hospital Estadual Mario Covas, ABC School of Medicine, Santo André, Brazil
Department of Surgery 1, Vladimir City Clinical Hospital of Emergency Medicine, Vladimir, Russian Federation
Cirugía General y Digestiva, Hospital Universitario Miguel Servet, Zaragoza, Spain
2nd Department of Surgery, Aretaieio University Hospital, Athens, Greece
Department of Surgery, Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Juiz de Fora, Brazil
Department of Surgery, Hospital Escola Padre Albino, Catanduva, Brazil
Department of Surgery, Ascoli Piceno Hospital, Ascoli Piceno, Italy
Department of General Surgery, Trabzon Kanuni Training and Research Hospital, Trabzon, Turkey
Department of Surgery, Government Medical College and Hospital, Chandigarh, India
Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
2nd Surgical Department of Medical Faculty Comenius University, University Hospital Bratislava, Bratislava, Slovakia
2nd Surgical Department, General Hospital of Kavala, Kavala, Greece
Department of Surgery, Mengucek Gazi Training Research Hospital, Erzincan, Turkey
Department of Emergency and Critical Care Medicine, Jichi Medical University, Shimotsuke, Japan
Department of Surgery, S M S Hospital, Jaipur, India
Department of Surgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania
Clinic for Emergency Surgery, Medical Faculty University of Belgrade, Belgrade, Serbia
Division Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
3rd Department of General Surgery, Jagiellonian Univeristy Collegium Medium, Kraków, Poland
Department of Emergency Surgery, City Hospital, Mozyr, Belarus
Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
Department of Surgery, Edendale Hospital, Pietermaritzburg, South Africa
Department of Surgery, University Clinical Center of Kosovo, Pristina, Kosovo
Department of General Surgery, Krishna Hospital, Karad, India
Department of General Surgery, Republican Vilnius University Hospital, Vilnius, Lithuania
Department of Surgery, York Teaching Hospital NHS Foundation Trust, York, UK
General Surgery/Coloretal Unit, Braga Hospital, Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
Department of Surgery, Hospital La Paz, Madrid, Spain
Cirugía de Urgencias, Hospital Universitario Donostia, Donostia, Spain
Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Department of Surgery, Insular University Hospital of Gran Canaria, Las Palmas, Spain
1st Department of Surgery, Kavala General Hospital, Kavala, Greece
Department of General Surgery, Mysore Medical College and Research Institute, Government Medical College Hospital Mysore, Mysore, India
2nd Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
First Department of Surgery, Tzaneio Hospital, Piraeus, Greece
Department of General Surgery and Surgical Oncology, Le Scotte Hospital, Siena, Italy
Department of Surgery, University Hospital, Valencia, Spain
Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
Department of Surgery, Radiology, University Hospital of the West Indies, Kingston, Jamaica
General Surgery Department, Centro Hospitalar de São João, Porto, Portugal
Second Surgical Clinic, Emergency Hospital of Craiova, Craiova, Romania
3rd Department of Surgery, Haepa University Hospital, Thessaloniki, Greece
Department of Surgery, CH Armentieres, Arras, France
Surgery Department, University Hospital Hassan II, Fez, Morocco
Department of Surgery, Onandjokwe Hospital, Ondangwa, Namibia
Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
Department of General Surgery, Lewisham & Greenwich NHS Trust, London, UK
Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
Department of Surgery, King Abdalla University Hospital, Irbid, Jordan
Department of Surgery, Elazig Training and Research Hospital, Elazig, Turkey
Department of Laparoscopic and Metabolic Surgery, Sunrise Hospital, Kochi, India
Department of Surgery, Sant’Antonio Abate Hospital, Gallarate, Italy
Division of Emergency and Trauma Surgery, Ribeirão Preto Medical School, Ribeirão Preto, Brazil
Surgery 1 Unit, Centro Hospitalar Tondela Viseu, Viseu, Portugal
Department of Surgery, UMC Ljubljana, Ljubljana, Slovenia
Department of Surgery, Bharati Medical College and Hospital, Sangli, India
Department of Surgery, Insubria University Hospital, Varese, Italy
Abdominal and General Surgery Department, General Hospital Jesenice, Jesenice, Slovenia
Department of Surgery, Hospital de Alta Especialidad de Veracruz, Veracruz, Mexico
General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
Department of Surgery, Fundación Jimenez Díaz, Madrid, Spain
Department of Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
Departement of Surgery, Fatabenefratelli Isola Tiberina Hspital, Rome, Italy
Department of Surgery, Hospital and Comprehensive Cancer Centre Novy Jicin, Novy Jicin, Czech Republic
Department of General Surgery, Clinical Hospital at Chelyabinsk Station of OJSC “Russian Railroads”, Chelyabinsk, Russian Federation
3th Department of Surgery, Iaso General Hospital, Athens, Greece
Department of Surgery, North Estonia Medical Center, Tallin, Estonia
Department of Surgery, Baskent University Ankara Hospital, Ankara, Turkey
General Surgery Service, Trauma University Hospital, Tirana, Albania
1st Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Prague, Czech Republic
Department of General Surgery, Sakarya Teaching and Research Hospital, Sakarya, Turkey
Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester, UK
Department of Surgery, Red Cross Hospital, Beverwijk, Netherlands
Emergency Surgery, Arcispedale S.Anna Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
Department of Surgery, Medical School University Pecs, Pecs, Hungary
Department of Surgery, Montichiari Hospital, Ospedali Civili Brescia, Brescia, Italy
1st Surgical Clinic, St. Spiridon Hospital, Iasi, Romania
Department of Surgery, Rajendra Institute of Medical Sciences, Ranchi, India
Department of Surgery, Kocaeli University Training and Research Hospital, Kocaeli, Turkey
Trauma and Emergency Surgery Department, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Department of Surgery, MOSC Medical College Kolenchery, Cochin, India
General and Digestive Surgery Department, Teaching Hospital Yalgado Ouedraogo, Ouagadougou, Burkina Faso


  1. Sartelli M, Viale P, Catena F, Ansaloni L, Moore E, Malangoni M, et al. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2013;8(1):3.PubMed CentralView ArticlePubMedGoogle Scholar
  2. Mulari K, Leppäniemi A. Severe secondary peritonitis following gastrointestinal tract perforation. Scand J Surg. 2004;93(3):204–8.PubMedGoogle Scholar
  3. Horiuchi A, Watanabe Y, Doi T, Sato K, Yukumi S, Yoshida M, et al. Evaluation of prognostic factors and scoring system in colonic perforation. World J Gastroenterol. 2007;13(23):3228–31.PubMed CentralView ArticlePubMedGoogle Scholar
  4. Evans HL, Raymond DP, Pelletier SJ, Crabtree TD, Pruett TL, Sawyer KG. Tertiary peritonitis (recurrent diffuse or localized disease) is not an independent predictor of mortality in surgical patients with intra-abdominal infection. Surg Infect. 2001;2:255–65.View ArticleGoogle Scholar
  5. McLauchlan GJ, Anderson ID, Grant IS, Fearon KCH. Outcome of patients with abdominal sepsis treated in an intensive care unit. Br J Surg. 1995;82:524–9.View ArticlePubMedGoogle Scholar
  6. Koperna T, Schulz F. Prognosis and treatment of peritonitis: Do we need new scoring systems? Arch Surg. 1996;131:180–6.View ArticlePubMedGoogle Scholar
  7. Pacelli F, Doglietto GB, Alfieri S, Piccioni E, Sgadari A, Gui D, et al. Prognosis in intra-abdominal infections. Multivariate analysis on 604 patients. Arch Surg. 1996;131:641–5.View ArticlePubMedGoogle Scholar
  8. Ohmann C, Yang Q, Hau T, Wacha H, the Peritonitis Study Group of the Surgical Infection Society Europe. Prognostic modelling in peritonitis. Eur J Surg. 1997;163:53–60.PubMedGoogle Scholar
  9. Montravers P, Gauzit R, Muller C, Marmuse JP, Fichelle A, Desmonts JM. Emergence of antibiotic-resistant bacteria in cases of peritonitis after intra-abdominal surgery affects the efficacy of empirical antimicrobial therapy. Clin Infect Dis. 1996;23:486–94.View ArticlePubMedGoogle Scholar
  10. Prabhu V, Shivani A. An overview of history, pathogenesis and treatment of perforated peptic ulcer disease with evaluation of prognostic scoring in adults. Ann Med Health Sci Res. 2014;4(1):22–9.PubMed CentralView ArticlePubMedGoogle Scholar
  11. Sartelli M, Catena F, Ansaloni L, Leppaniemi A, Taviloglu K, van Goor H, et al. Complicated intra-abdominal infections in Europe: a comprehensive review of the CIAO study. World J Emerg Surg. 2012;7(1):36.PubMed CentralView ArticlePubMedGoogle Scholar
  12. Sartelli M, Catena F, Ansaloni L, Coccolini F, Corbella D, Moore EE, et al. Complicated intra-abdominal infections worldwide: the definitive data of the CIAOW Study. World J Emerg Surg. 2014;9:37.PubMed CentralView ArticlePubMedGoogle Scholar
  13. Sartelli M. A focus on intra-abdominal infections. World J Emerg Surg. 2010;5:9.PubMed CentralView ArticlePubMedGoogle Scholar
  14. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165–228.View ArticlePubMedGoogle Scholar
  15. Mazuski JE, Solomkin JS. Intra-abdominal infections. Surg Clin North Am. 2009;89(2):421–37.View ArticlePubMedGoogle Scholar
  16. Merlino JI, Malangoni MA, Smith CM, Lange RL. Prospective randomized trials affect the outcomes of intraabdominal infection. Ann Surg. 2001;233(6):859–66.PubMed CentralView ArticlePubMedGoogle Scholar
  17. Komatsu S, Shimomatsuya T, Nakajima M, Amaya H, Kobuchi T, Shiraishi S, et al. Prognostic factors and scoring system for survival in colonic perforation. Hepatogastroenterology. 2005;52:761–64.PubMedGoogle Scholar
  18. Koperna T, Semmler D, Marian F. Risk stratification in emergency surgical patients: is the APACHE II score a reliable marker of physiological impairment? Arch Surg. 2001;136(1):55–9.View ArticlePubMedGoogle Scholar
  19. Wacha H, Linder MM, Feldman U, Wesch G, Gundlach E, Steifensand RA. Mannheim peritonitis index – prediction of risk of death from peritonitis: construction of a statistical and validation of an empirically based index. Theor Surg. 1987;1:169–77.Google Scholar


© Sartelli et al. 2015