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Intra-abdominal sepsis: a medical-surgical dilemma
1New England Medical Center Hospital, Boston, Massachusetts.
Abstract:
Much progress has been made in our understanding of the pathophysiology of intra-abdominal infection over the past 100 years. By 1900, investigators had evidence of both an aerobic and an anaerobic component in these infections. By the 1970s, the role of gram-negative aerobic organisms in peritonitis and the role of anaerobes in abscess formation were emerging. Improved culture techniques have demonstrated the true polymicrobial nature of intra-abdominal infection. In our most recent study, an average of 3.9 isolates per patient was cultured. Because of the mixed flora present in these infections, antibiotic regimens must be active against both aerobes and anaerobes. This coverage has usually been accomplished with combinations of antibiotics, although some newer, single-agent regimens may also be effective. Even with our increased knowledge, intra-abdominal infection followed by sepsis remains the most common cause of death among patients in the intensive care unit. Mortality is associated with multiple, recurrent, or persisting abscess; positive blood cultures; and organ failure. Surgery, if indicated, should be undertaken before the onset of significant organ failure. Reducing the mortality from organ failure will depend more on the ability to modulate the metabolic and immune pathways that lead to sepsis than on the development of broader-spectrum antibiotics and more aggressive surgical algorithms.
Insights
Intra-abdominal infections involve both aerobic and anaerobic bacteria, requiring broad-spectrum antibiotics. Despite advances, sepsis from these infections remains a leading cause of intensive care unit mortality, necessitating new treatment strategies.
Area of Science:
- Infectious Diseases
- Microbiology
- Critical Care Medicine
Background:
- Intra-abdominal infections (IAIs) have a complex pathophysiology involving aerobic and anaerobic microorganisms.
- Understanding of IAIs evolved over a century, with key insights into peritonitis and abscess formation by the 1970s.
- Improved culture techniques reveal the polymicrobial nature of IAIs, with an average of 3.9 isolates per patient.
Purpose of the Study:
- To review the pathophysiology and treatment of intra-abdominal infections.
- To highlight the challenges posed by polymicrobial flora in antibiotic selection.
- To discuss mortality factors and future directions in managing sepsis secondary to IAIs.
Main Methods:
- Literature review of the pathophysiology of intra-abdominal infections over the past 100 years.
- Analysis of historical and recent findings on microbial components (aerobic and anaerobic) in IAIs.
- Discussion of current antibiotic strategies and their limitations.
Main Results:
- IAIs are polymicrobial, necessitating antibiotic regimens active against both aerobic and anaerobic bacteria.
- Current antibiotic approaches often involve combinations, though single-agent regimens are emerging.
- Despite advances, IAIs leading to sepsis remain a primary cause of death in intensive care units.
Conclusions:
- Effective management of IAIs requires addressing both aerobic and anaerobic components.
- Mortality in IAIs is linked to recurrent abscesses, positive blood cultures, and organ failure.
- Future reductions in mortality will likely depend on modulating sepsis-related metabolic and immune pathways, rather than solely on broader antibiotics or surgery.