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Percutaneously drained intra-abdominal infections do not require longer duration of antimicrobial therapy
Rishi Rattan1, Casey J Allen, Robert G Sawyer
1From the Department of Surgery (R.R., C.J.A., N.N.), University of Miami Miller School of Medicine, Miami, Florida; Departments of Surgery and Public Health Sciences (R.G.S.), University of Virginia Health Systems, Charlottesville, Virginia; Department of Surgery (R.A.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery (K.L.B.), University of Minnesota Medical Center, Minneapolis, Minnesota; Department of Surgery (R.C.), University of California San Diego, San Diego, California; Department of Surgery (C.H.C.), Beth Israel Deaconnness Medical Center, Boston, Massachusetts; Department of Surgery (T.M.D.), Virginia Commonwealth University, Richmond, Virginia; Department of Surgery (P.J.O.), Maricopa Integrated Health System, Phoenix, Arizona; Department of Surgery (O.D.R.), University of Toronto St. Michael's Hospital, Toronto, ON, Canada.
Background:
The length of antimicrobial therapy in complicated intra-abdominal infections (CIAIs) is controversial. A recent prospective, multicenter, randomized controlled trial found that 4 days of antimicrobial therapy after source control of CIAI resulted in similar outcomes when compared with longer duration. We sought to examine whether outcomes remain similar in the subpopulation who received percutaneous drainage for source control of CIAI.
Methods:
With the use of the STOP-IT database, patients with a CIAI who received percutaneous drainage were analyzed. Patients were randomized to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 days of therapy or to receive a fixed course of antibiotics for 4 ± 1 days. Outcomes included incidence of and time to recurrent intra-abdominal infection, Clostridium difficile infection, and extra-abdominal infections as well as hospital days and mortality.
Results:
Of 518 enrolled patients, 129 met inclusion criteria. Baseline characteristics, including demographics, comorbidities, and severity of illness, were similar. When comparing outcomes of the 4-day group (n = 72) with those of the longer group (n = 57), rates of recurrent intra-abdominal infection (9.7% vs. 10.5%, p = 1.00), C. difficile infection (0% vs. 1.8%, p = 0.442), and hospital days (4.0 [2.0-7.5] vs. 4.0 [3.0-8.0], p = 0.91) were similar. Time to recurrent infection was shorter in the 4-day group (12.7 [6.2] days vs. 21.3 [4.2] days, p = 0.015). There was no mortality.
Conclusion:
In this post hoc analysis of a prospective, multicenter, randomized trial, there was no difference in outcome between a shorter and longer duration of antimicrobial therapy in those with percutaneously drained source control of CIAI.
Level Of Evidence:
Therapeutic/care management study, level IV.
Insights
A shorter, 4-day course of antibiotics is as effective as a longer duration for complicated intra-abdominal infections treated with percutaneous drainage. This finding supports de-escalation of antimicrobial therapy in specific patient populations.
Area of Science:
- Infectious Diseases
- Surgical Infections
- Antimicrobial Stewardship
Background:
- The optimal duration of antimicrobial therapy for complicated intra-abdominal infections (CIAI) remains debated.
- A prior trial indicated similar outcomes with 4 days versus longer antibiotic courses post-source control for CIAI.
- This study specifically investigates outcomes in patients undergoing percutaneous drainage for CIAI source control.
Purpose of the Study:
- To evaluate the efficacy of a 4-day antimicrobial therapy course compared to a longer duration in patients with CIAI treated with percutaneous drainage.
- To analyze key clinical outcomes including infection recurrence, Clostridium difficile infection, and hospital length of stay.
Main Methods:
- A post hoc analysis of the STOP-IT trial database, focusing on patients who received percutaneous drainage for CIAI.
- Patients were randomized to either a fixed 4 ± 1 day antibiotic course or antibiotics until clinical resolution (max 10 days).
- Outcomes assessed included recurrent intra-abdominal infection, C. difficile infection, extra-abdominal infections, hospital days, and mortality.
Main Results:
- Among 129 patients who underwent percutaneous drainage, baseline characteristics were similar between groups.
- No significant differences were observed in recurrent intra-abdominal infection (9.7% vs. 10.5%), C. difficile infection (0% vs. 1.8%), or hospital days (4.0 vs. 4.0).
- Time to recurrent infection was shorter in the 4-day group (12.7 days) compared to the longer duration group (21.3 days), though overall outcomes were similar. No mortality was reported.
Conclusions:
- A shorter, 4-day antimicrobial therapy duration is non-inferior to longer durations for complicated intra-abdominal infections managed with percutaneous drainage.
- These findings support the use of shorter antibiotic courses in this specific patient subgroup, contributing to antimicrobial stewardship efforts.
- Percutaneous drainage as source control for CIAI allows for similar outcomes with abbreviated antibiotic therapy.
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