• Apoptosis
• Clemastine
• Kidney injury
• Sepsis
• TLR4

• Animals
• Acute Kidney Injury/metabolism
• Acute Kidney Injury/drug therapy
• Acute Kidney Injury/etiology
• Acute Kidney Injury/prevention & control
• Acute Kidney Injury/pathology
• Toll-Like Receptor 4/metabolism
• Sepsis/complications
• Sepsis/metabolism
• Sepsis/drug therapy
• Myeloid Differentiation Factor 88/metabolism
• NF-kappa B/metabolism
• Rats
• Caspase 3/metabolism
• Male
• p38 Mitogen-Activated Protein Kinases/metabolism
• Klotho Proteins
• Glucuronidase/metabolism
• Glucuronidase/genetics
• Signal Transduction/drug effects
• Rats, Sprague-Dawley
• Apoptosis/drug effects

• Humans
• Abdominal Injuries/surgery
• Abdomen/surgery
• Abdominal Cavity
• Resuscitation/methods

The pathogenic role of staphylococci in hospital-acquired postoperative intra-abdominal infections (HAIs) has never been evaluated. In a tertiary care university hospital, we assessed the clinical characteristics and outcomes of patients admitted to the intensive care unit for HAIs according to the presence of staphylococci (S-HAI) or their absence (nS-HAI) in peritoneal cultures. Patients with S-HAIs were compared to nS-HAIs patients. Overall, 380 patients were analyzed, including 87 (23%) S-HAI patients [29 Staphylococcus aureus (Sa-HAIs) and 58 coagulase-negative staphylococci (CoNS-HAIs)]. The clinical characteristics did not differ between the S-HAI and nS-HAI patients. Adequacy of empirical anti-infective therapy was achieved less frequently in the staphylococci group (54 vs 72%, respectively, p < 0.01). The 90-day (primary endpoint) and one-year mortality rates did not differ between these groups. The S-HAI patients had decreased rates of postoperative complication (p < 0.05). The adjusted analysis of the clinical outcomes reported a decreased frequency of surgical complications in the staphylococci group (OR 0.43, 95% CI [0.20–0.93], p = 0.03). While the trends toward decreased morbidity criteria were observed in S-HAI patients, the clinical outcomes were not different between the CoNS-HAI and Sa-HAI patients. In summary, our data are not substantial enough to conclude that staphylococci exhibit no pathogenicity in HAIs.

• Intra-abdominal infection
• Open abdomen
• Source control
• Source control failure

• Decision-making
• GenOSept
• Genetic epidemiology
• Human genetics
• Intensive care
• Research ethics

• Confidentiality/ethics
• Critical Illness/therapy
• Ethics Committees, Research/organization & administration
• Europe
• Humans
• Informed Consent/ethics
• International Cooperation
• Mental Competency
• Molecular Epidemiology/ethics
• Surveys and Questionnaires

• Wellcome Trust
• G0900747 91070 Medical Research Council
• RP-2015-06-018 Department of Health
• 090532/Z/09/Z Wellcome Trust
• EU
• National Institute for Health Research
• Bundesministerium für Bildung und Forschung
• Thüringer Ministerium für Bildung, Wissenschaft und Kultur

• Critically ill
• Epidemiology
• Intra-abdominal infection
• Sepsis
• Surgery
• Therapy

Bloodstream infections of abdominal origin are usually associated with poor prognosis. We assessed the clinical and microbiological characteristics of critically ill patients admitted to the intensive care unit (ICU) for postoperative intra-abdominal infection (PIAI) and analysed the influence of bacteraemia on their outcome.

All consecutive PIAI patients admitted to the ICU between 1999 and 2014 were prospectively analysed. Bacteraemic patients (at least one positive blood culture in the 24 h preceding/following surgery) were compared with non-bacteraemic patients. Demographic characteristics, underlying disease, severity scores at the time of reoperation, microbiological results, therapeutic management, outcome, and survival were recorded. Results are expressed as median (interquartile range (IQR)) or proportions.

Overall, 343 patients (54% male, 62 (49–73) years old) with PIAI were analysed, including 64 (19%) bacteraemic patients. Immunosuppression and cancer were more frequent in bacteraemic patients (p < 0.001 in both cases). No difference between groups was observed for the characteristics of initial surgery. Time to reoperation, site, and cause of PIAI were similar in both groups. At the time of reoperation, Sequential Organ Failure Assessment (SOFA) score was higher in bacteraemic patients (8 (6–10) versus 7 (4–10); p < 0.05). A predominance of Gram-positive (34%) and Gram-negative (47%) bacteria were recovered from blood cultures (polymicrobial bacteraemia in 9 (14%) patients and bacteraemia involving multidrug-resistant organisms in 14 (22%) patients). In multivariate analysis, risk factors for bacteraemia were immunosuppression or cancer, high SOFA score, and E. coli in peritoneal samples. Bacteraemia did not impact the management (with similar results for the adequacy of antibiotic therapy, anti-infective agents used, de-escalation or duration of therapy in both groups). Neither hospital mortality nor morbidity criteria differed between groups. Risk factors for mortality in multivariate analysis were urgent initial surgery, high Simplified Acute Physiology Score (SAPS) II score and documented antifungal therapy, but not perioperative bacteraemia.

In this ICU population, bacteraemia did not change the overall management of patients with PIAI. Our data suggest that bacteraemic patients do not require a specific management.

• Bacteraemia
• Intra-abdominal infection
• Outcome
• Postoperative infection

• Burns
• SIRS
• SOFA
• definition
• sepsis
• sepsis 3

To identify the risk factors for mortality in intensive care patients with postoperative peritonitis (POP).

This was a retrospective analysis using a prospective database that includes all patients hospitalized in a surgical intensive care unit for POP from September 2006 to August 2011. The data collected included demographics, comorbidities, postoperative severity parameters, bacteriological findings, adequacy of antimicrobial therapy and surgical treatments. Adequate source control was defined based on a midline laparotomy, infection source control and intraoperative peritoneal lavage. The number of reoperations needed was also recorded.

A total of 201 patients were included. The overall mortality rate was 31%. Three independent risk factors for mortality were identified: The Simplified Acute Physiological II Score (OR = 1.03; 95%CI: 1.02-1.05, P < 0.001), postoperative medical complications (OR = 6.02; 95%CI: 1.95-18.55, P < 0.001) and the number of reoperations (OR = 2.45; 95%CI: 1.16-5.17, P = 0.015). Surgery was considered as optimal in 69% of the cases, but without any significant effect on mortality.

The results from the large cohort in this study emphasize the role of the initial postoperative severity parameters in the prognosis of POP. No predefined criteria for optimal surgery were significantly associated with increased mortality, although the number of reoperations appeared as an independent risk factor of mortality.

• Mortality
• Postoperative peritonitis
• Risk factors
• Surgery

De-escalation is strongly recommended for antibiotic stewardship. No studies have addressed this issue in the context of health care-associated intra-abdominal infections (HCIAI). We analyzed the factors that could interfere with this process and their clinical consequences in intensive care unit (ICU) patients with HCIAI.

All consecutive patients admitted for the management of HCIAI who survived more than 3 days following their diagnosis, who remained in the ICU for more than 3 days, and who did not undergo early reoperation during the first 3 days were analyzed prospectively in an observational, single-center study in a tertiary care university hospital.

Overall, 311 patients with HCIAI were admitted to the ICU. De-escalation was applied in 110 patients (53 %), and no de-escalation was reported in 96 patients (47 %) (escalation in 65 [32 %] and unchanged regimen in 31 [15 %]). Lower proportions of Enterococcus faecium, nonfermenting Gram-negative bacilli (NFGNB), and multidrug-resistant (MDR) strains were cultured in the de-escalation group. No clinical difference was observed at day 7 between patients who were de-escalated and those who were not. Determinants of de-escalation in multivariate analysis were adequate empiric therapy (OR 9.60, 95 % CI 4.02–22.97) and empiric use of vancomycin (OR 3.39, 95 % CI 1.46–7.87), carbapenems (OR 2.64, 95 % CI 1.01–6.91), and aminoglycosides (OR 2.31 95 % CI 1.08–4.94). The presence of NFGNB (OR 0.28, 95 % CI 0.09–0.89) and the presence of MDR bacteria (OR 0.21, 95 % CI 0.09–0.52) were risk factors for non-de-escalation. De-escalation did not change the overall duration of therapy. The risk factors for death at day 28 were presence of fungi (HR 2.64, 95 % CI 1.34–5.17), Sequential Organ Failure Assessment score on admission (HR 1.29, 95 % CI 1.16–1.42), and age (HR 1.03, 95 % CI 1.01–1.05). The survival rate expressed by a Kaplan-Meier curve was similar between groups (log-rank test p value 0.176).

De-escalation is a feasible option in patients with polymicrobial infections such as HCIAI, but MDR organisms and NFGNB limit its implementation.

• Antibiotic therapy
• De-escalation
• Health care-associated intra-abdominal infections
• Multidrug-resistant bacteria
• Peritonitis

Patients admitted to intensive care following surgery for faecal peritonitis present particular challenges in terms of clinical management and risk assessment. Collaborating surgical and intensive care teams need shared perspectives on prognosis. We aimed to determine the relationship between dynamic assessment of trends in selected variables and outcomes.

We analysed trends in physiological and laboratory variables during the first week of intensive care unit (ICU) stay in 977 patients at 102 centres across 16 European countries. The primary outcome was 6-month mortality. Secondary endpoints were ICU, hospital and 28-day mortality. For each trend, Cox proportional hazards (PH) regression analyses, adjusted for age and sex, were performed for each endpoint.

Trends over the first 7 days of the ICU stay independently associated with 6-month mortality were worsening thrombocytopaenia (mortality: hazard ratio (HR) = 1.02; 95% confidence interval (CI), 1.01 to 1.03; P <0.001) and renal function (total daily urine output: HR =1.02; 95% CI, 1.01 to 1.03; P <0.001; Sequential Organ Failure Assessment (SOFA) renal subscore: HR = 0.87; 95% CI, 0.75 to 0.99; P = 0.047), maximum bilirubin level (HR = 0.99; 95% CI, 0.99 to 0.99; P = 0.02) and Glasgow Coma Scale (GCS) SOFA subscore (HR = 0.81; 95% CI, 0.68 to 0.98; P = 0.028). Changes in renal function (total daily urine output and renal component of the SOFA score), GCS component of the SOFA score, total SOFA score and worsening thrombocytopaenia were also independently associated with secondary outcomes (ICU, hospital and 28-day mortality). We detected the same pattern when we analysed trends on days 2, 3 and 5. Dynamic trends in all other measured laboratory and physiological variables, and in radiological findings, changes inrespiratory support, renal replacement therapy and inotrope and/or vasopressor requirements failed to be retained as independently associated with outcome in multivariate analysis.

Only deterioration in renal function, thrombocytopaenia and SOFA score over the first 2, 3, 5 and 7 days of the ICU stay were consistently associated with mortality at all endpoints. These findings may help to inform clinical decision making in patients with this common cause of critical illness.

The online version of this article (doi:10.1186/s13054-015-0931-8) contains supplementary material, which is available to authorized users.

Persistent peritonitis is a frequent complication of secondary peritonitis requiring additional reoperations and antibiotic therapy. This situation raises specific concerns due to microbiological changes in peritoneal samples, especially the emergence of multidrug-resistant (MDR) strains. Although this complication has been extensively studied, the rate and dynamics of MDR strains have rarely been analysed.

We compared the clinical, microbiological and therapeutic data of consecutive ICU patients admitted for postoperative peritonitis either without subsequent reoperation (n = 122) or who underwent repeated surgery for persistent peritonitis with positive peritoneal fluid cultures (n = 98). Data collected on index surgery for the treatment of postoperative peritonitis were compared between these two groups. In the patients with persistent peritonitis, the data obtained at the first, second and third reoperations were compared with those of index surgery. Risk factors for emergence of MDR strains were assessed.

At the time of index surgery, no parameters were able to differentiate patients with or without persistent peritonitis except for increased severity and high proportions of fungal isolates in the persistent peritonitis group. The mean time to reoperation was similar from the first to the third reoperation (range: 5 to 6 days). Septic shock was the main clinical expression of persistent peritonitis. A progressive shift of peritoneal flora was observed with the number of reoperations, comprising extinction of susceptible strains and emergence of 85 MDR strains. The proportion of patients harbouring MDR strains increased from 41% at index surgery, to 49% at the first, 54% at the second (P = 0.037) and 76% at the third reoperation (P = 0.003 versus index surgery). In multivariate analysis, the only risk factor for emergence of MDR strains was time to reoperation (OR 1.19 per day, 95%CI (1.08 to 1.33), P = 0.0006).

Initial severity, presence of Candida in surgical samples and inadequate source control are the major risk factors for persistent peritonitis. Emergence of MDR bacteria is frequent and increases progressively with the number of reoperations. No link was demonstrated between emergence of MDR strains and antibiotic regimens, while source control and its timing appeared to be major determinants of emergence of MDR strains.

• ICU
• abdominal compartment syndrome,
• intra-abdominal hypertension,
• intra-abdominal sepsis,
• peritonitis,

Our aim was to describe inflammatory cytokines response in the peritoneum and plasma of patients with peritonitis. We also tested the hypothesis that scenarios associated with worse outcome would result in different cytokine release patterns. Therefore, we compared cytokine responses according to the occurrence of septic shock, mortality, type of peritonitis and peritoneal microbiology.

Peritoneal and plasma cytokines (interleukin (IL) 1, tumor necrosis factor α (TNFα), IL-6, IL-10, and interferon γ (IFNγ)) were measured in 66 patients with secondary peritonitis.

The concentration ratio between peritoneal fluid and plasma cytokines varied from 5 (2 to 21) (IFNγ) to 1310 (145 to 3888) (IL-1). There was no correlation between plasma and peritoneal fluid concentration of any cytokine. In the plasma, TNFα, IL-6, IFNγ and IL-10 were higher in patients with shock versus no shock and in nonsurvivors versus survivors (P ≤0.03). There was no differential plasma release for any cytokine between community-acquired and postoperative peritonitis. The presence of anaerobes or Enterococcus species in peritoneal fluid was associated with higher plasma TNFα: 50 (37 to 106) versus 38 (29 to 66) and 45 (36 to 87) versus 39 (27 to 67) pg/ml, respectively (P = 0.02). In the peritoneal compartment, occurrence of shock did not result in any difference in peritoneal cytokines. Peritoneal IL-10 was higher in patients who survived (1505 (450 to 3130) versus 102 (9 to 710) pg/ml; P = 0.04). The presence of anaerobes and Enterococcus species was associated with higher peritoneal IFNγ: 2 (1 to 6) versus 10 (5 to 28) and 7 (2 to 39) versus 2 (1 to 6), P = 0.01 and 0.05, respectively).

Peritonitis triggers an acute systemic and peritoneal innate immune response with a simultaneous release of pro and anti-inflammatory cytokines. Higher levels of all cytokines were observed in the plasma of patients with the most severe conditions (shock, non-survivors), but this difference was not reflected in their peritoneal fluid. There was always a large gradient in cytokine concentration between peritoneal and plasma compartments highlighting the importance of compartmentalization of innate immune response in peritonitis.

• Adrenergic alpha-Agonists/administration & dosage
• Aged
• Biomarkers/blood
• C-Reactive Protein/metabolism
• Colectomy/mortality
• Colitis/blood
• Colitis/etiology
• Colitis/mortality
• Colitis/surgery
• Drug Administration Schedule
• Emergencies
• Female
• Humans
• Intensive Care Units
• Lactic Acid/blood
• Leukocyte Count
• Linear Models
• Male
• Middle Aged
• Norepinephrine/administration & dosage
• Organ Dysfunction Scores
• Preoperative Period
• Prognosis
• Retrospective Studies
• Survival Rate

• APACHE
• Adult
• Age Factors
• Aged
• Blood Coagulation/physiology
• Cardiovascular System/physiopathology
• Central Nervous System/physiopathology
• Female
• Follow-Up Studies
• Hospital Mortality
• Humans
• Intensive Care Units
• Intestinal Perforation/mortality
• Intestinal Perforation/physiopathology
• Intestinal Perforation/surgery
• Kidney/physiopathology
• Length of Stay
• Liver/physiopathology
• Lung/physiopathology
• Male
• Middle Aged
• Multiple Organ Failure/mortality
• Multiple Organ Failure/physiopathology
• Peritonitis/mortality
• Peritonitis/physiopathology
• Peritonitis/surgery
• Postoperative Complications/mortality
• Postoperative Complications/physiopathology
• Postoperative Complications/surgery
• Prognosis
• Reoperation
• Risk Factors

• Abdominal Wall/surgery
• Anastomosis, Surgical
• Critical Illness
• Humans
• Laparotomy
• Peritoneum/anatomy & histology
• Peritoneum/physiology
• Peritonitis/classification
• Peritonitis/diagnosis
• Peritonitis/surgery
• Peritonitis/therapy
• Reoperation
• Resuscitation
• Therapeutic Irrigation

• D43 TW007560 FIC NIH HHS
• D43 TW007560-05 FIC NIH HHS
• 1D43 TW 007560-01 FIC NIH HHS

• Adult
• Aged
• Aged, 80 and over
• Critical Illness
• Female
• Humans
• Lactic Acid/blood
• Laparotomy/adverse effects
• Male
• Microdialysis
• Middle Aged
• Peritoneal Dialysis
• Pilot Projects
• Predictive Value of Tests
• Pyruvic Acid/blood

• Hospital Mortality
• Humans
• Laparotomy
• Patient Care Team
• Peritonitis/mortality
• Peritonitis/surgery
• Postoperative Complications/mortality
• Postoperative Complications/surgery
• Prognosis
• Reoperation
• Risk Factors
• Surgical Wound Infection/mortality
• Surgical Wound Infection/surgery
• Survival Rate

• Abdominal Abscess/etiology
• Abdominal Abscess/mortality
• Abdominal Abscess/surgery
• Aged
• Cohort Studies
• Critical Illness
• Drainage
• Female
• Humans
• Intensive Care Units
• Intestinal Perforation/complications
• Longitudinal Studies
• Male
• Middle Aged
• Multiple Organ Failure/etiology
• Multiple Organ Failure/mortality
• Multiple Organ Failure/surgery
• Outcome Assessment, Health Care
• Peritonitis/etiology
• Peritonitis/mortality
• Peritonitis/surgery
• Prospective Studies

• Abdomen
• Cross Infection/diagnosis
• Cross Infection/epidemiology
• Cross Infection/therapy
• Humans
• Multiple Organ Failure
• Peritonitis/diagnosis
• Peritonitis/therapy
• Sepsis
• Shock/prevention & control
• Treatment Outcome

• Abscess/diagnosis
• Abscess/diagnostic imaging
• Abscess/microbiology
• Abscess/therapy
• Anti-Infective Agents/administration & dosage
• Bacterial Infections/diagnosis
• Bacterial Infections/diagnostic imaging
• Bacterial Infections/microbiology
• Bacterial Infections/therapy
• Critical Care/methods
• Critical Illness
• Drainage
• Humans
• Intensive Care Units
• Peritonitis/diagnosis
• Peritonitis/diagnostic imaging
• Peritonitis/microbiology
• Peritonitis/therapy
• Radiography

• Aged
• Anti-Bacterial Agents/adverse effects
• Ascitic Fluid/microbiology
• Bacterial Infections/complications
• Bacterial Infections/microbiology
• Candida/isolation & purification
• Candidiasis/complications
• Candidiasis/microbiology
• Candidiasis/mortality
• Cross Infection/complications
• Cross Infection/microbiology
• Cross Infection/mortality
• Female
• Hospital Mortality
• Humans
• Infection Control/methods
• Intensive Care Units
• Logistic Models
• Male
• Middle Aged
• Multiple Organ Failure/microbiology
• Peritonitis/complications
• Peritonitis/microbiology
• Peritonitis/mortality
• Predictive Value of Tests
• Prospective Studies
• Retrospective Studies
• Risk Factors
• Severity of Illness Index
• Survival Analysis
• Time Factors

• acute respiratory failure
• intensive care
• organ failure
• outcome
• sequential organ failure assessment
• survival

• Adult
• Critical Illness
• Hospital Mortality
• Humans
• Intensive Care Units
• Multiple Organ Failure
• Norway/epidemiology
• Prospective Studies
• Respiratory Insufficiency/mortality
• Respiratory Insufficiency/physiopathology
• Severity of Illness Index
• Treatment Outcome