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Peritonitis into the 1990s: changing pathogens and changing strategies in the critically ill
R G Sawyer1, L K Rosenlof, R B Adams
1Department of Surgery, University of Virginia Medical Center, Charlottesville 22908.
Insights
In severely ill patients, intra-abdominal infections show different microbiology. Longitudinal clinical scoring, not single scores, better predicts outcomes for these critical patients.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Surgical Infections
Background:
- Severe illness alters the characteristics of peritonitis and intra-abdominal abscesses.
- High Acute Physiology and Chronic Health Evaluation (APACHE) II scores (≥15) indicate a predicted mortality of at least 50%.
Purpose of the Study:
- To investigate the impact of severe illness on the microbiology and clinical course of intra-abdominal infections.
- To evaluate the predictive value of preoperative and longitudinal clinical scoring in severely ill patients.
Main Methods:
- Analysis of culture-proven intra-abdominal infections in 29 severely ill patients (APACHE II score ≥15).
- Examination of preoperative and serial (Days 3 and 7) APACHE II scores.
- Microbiological analysis of peritoneal fluid.
Main Results:
- Overall mortality was 52%, correlating with higher APACHE II scores.
- Candida albicans was the most common organism, followed by Enterococcus, Enterobacter, and Staphylococcus epidermidis.
- Increasing APACHE II scores from baseline to Day 7 predicted 91% mortality, while decreasing scores predicted 22% mortality.
Conclusions:
- The microbiology of intra-abdominal infections differs significantly in severely ill patients.
- Longitudinal clinical scoring is more effective than single scoring for predicting patient outcomes.
- Further trials are warranted to explore broader perioperative antimicrobial coverage and use of longitudinal scoring for guiding reintervention.
Abstract:
To study the effect of severe illness on the nature of peritonitis and intra-abdominal abscesses, the microbiology and clinical course of patients operated on over a 1-year period with culture-proven intra-abdominal infections whose preoperative Acute Physiology and Chronic Health Evaluation (APACHE) II scores were greater than or equal to 15 (predicted mortality at least 50%) were examined. Twenty-nine patients were enrolled, and overall mortality was 52 per cent, with increasing mortality correlating with higher APACHE II scores. The organism most commonly isolated from the peritoneum was Candida albicans, followed by Enterococcus species, Enterobacter species, and Staphylococcus epidermidis. An increase in the mean of the APACHE II scores on Days 3 and 7 compared to the preoperative score was associated with a 91 per cent mortality, while a decrease was associated with only a 22 per cent mortality. The authors conclude that the microbiology of intra-abdominal infections is inherently different in severely ill patients and that longitudinal clinical scoring may be more useful than a single scoring in predicting outcome. These data suggest that trials to investigate the broadening of standard perioperative antimicrobial coverage in the ill and use of longitudinal clinical scoring to direct aggressive reintervention may be warranted.