成人医疗保健相关性复杂性腹腔感染的危险因素分析

背景与目的:复杂性腹腔感染(cIAI)是外科术后并发的第二大最常见的感染,虽然目前诊疗水平在不断提高,但是cIAI的病死率仍高,住院期间并发cIAI,不仅危及患者的生命,并且对患者的长期预后产生不利影响。本研究探讨医疗保健相关性cIAI(HA-cIAI)的危险因素,为临床诊疗活动中采取适当的干预措施提供依据,以期降低HA-cIAI的发生率。方法:回顾性分析2011年11月—2016年7月在中南大学湘雅医院住院期间留取腹腔积液标本行快速细菌需氧培养阳性并临床诊断为cIAI的359例成人患者的临床资料,其中社区获得性cIAI患者143例(CA-cIAI组),HA-cIAI 216例(HA-cIAI组)。比较两组患者的一般资料、治疗情况及实验室指标,对HA-cIAI进行相关危险因素分析。结果:与CA-cIAI组比较,HA-cIAI组≥60岁的患者比例增高、平均住院时间延长、腹部恶性肿瘤及住院期间行腹部手术患者比例增加、血红蛋白与降钙素原水平降低,而谷丙转氨酶水平升高(均P0.05);两组住院期间行腹部手术的患者中,HA-cIAI组手术持续时间≥3 h、术中出血量≥200 mL、留置腹腔引流管时间≥10 d、留置导尿管及留置时间≥7 d和术前使用抗菌药物患者的比例均明显高于CA-cIAI组(均P0.05)。Logistic回归分析显示,住院时间≥15 d(OR=6.946,95% CI=3.786～12.743,P0.05)及腹部恶性肿瘤(OR=2.880,95% CI=1.538～5.390,P0.05)是HA-cIAI的独立危险因素。结论:中老年、腹部恶性肿瘤、住院时间长及手术持续时间长、术中出血量大、留置腹腔引流管时间长、留置导尿管及留置时间长和术前使用抗菌药物,特别是住院时间≥15 d及腹部恶性肿瘤为HA-cIAI的危险因素,对于有以上因素的患者,需根据情况采取有效的预防措施,以防HA-cIAI的发生。     

Postoperative enterococcal infection after treatment of complicated intra-abdominal sepsis

BACKGROUND: The prevalence of enterococcal isolation and factors associated with postoperative enterococcal infection remain ill defined. METHODS: A prospective longitudinal observational study was conducted of consecutive patients with a first episode of intra-abdominal infection and a positive microbiological culture who did or did not develop a postoperative septic complication involving enterococci. The prevalence of initial enterococcal isolation was determined for each focus of infection. Postoperative enterococcal infections were related to whether appropriate (piperacillin--tazobactam), suboptimal (carbapenems) or inappropriate (cefotaxime plus metronidazole) antienterococcal therapy had been administered empirically. RESULTS: Enterococci were isolated in 42 (21 per cent) of the 200 patients investigated. The isolation rates were 11 per cent for community-acquired peritonitis, 50 per cent for postoperative peritonitis and 23 per cent for intra-abdominal abscesses of both origins. No enterococci were isolated from 49 patients with perforated appendicitis. Independent factors for postoperative enterococcal infection were type of intra-abdominal infection (P = 0.006), Acute Physiology And Chronic Health Evaluation (APACHE) II score greater than 12 (P = 0.04) and inappropriate empirical antibiotic cover (P = 0.05). Postoperative enterococcal infections were associated with a high mortality rate (21 versus 4 per cent; P < 0.0007). CONCLUSION: Enterococci are frequently isolated from intra-abdominal infections of non-appendiceal origin and are often involved in postoperative infectious complications, particularly peritonitis. Empirical antibiotic therapy covering Enterococcus faecalis should be contemplated in some circumstances.     

Pharmacoeconomics of ciprofloxacin plus metronidazole vs. piperacillin-tazobactam for complicated intra-abdominal infections

BACKGROUND: A series of 459 hospitalized adults with complicated intra-abdominal infections participated in a randomized, double-blind, multicenter clinical trial. The present study was conducted to add a pharmacoeconomic analysis to the results. METHODS: A cost-effectiveness analysis from the perspective of the hospital provider was carried out. Decision analysis was used to illustrate outcomes and to provide a basis on which to conduct a sensitivity analysis. Cost-effectiveness ratios, representing the cost per expected successfully treated patient, were calculated to determine the most cost-effective alternative. RESULTS: Among 244 economically evaluable patients, enrolled from 34 centers in the U.S. and Canada, 131 patients received ciprofloxacin-metronidazole (75% clinical success rate), and 113 received piperacillin-tazobactam (65% clinical success rate; p = 0.06). Switch to oral antibiotics was possible for 81 patients who received ciprofloxacin-metronidazole (85% clinical success rate) and 67 piperacillin-tazobactam patients (70% clinical success rate; p = 0.027). The mean hospital cost was US$10,662 +/- 7,793 for patients in the ciprofloxacin-metronidazole group and $10,009 +/- 7,023 for patients in the piperacillin-tazobactam group (p = 0.492). Significantly lower costs were documented for patients who could be switched to oral antibiotics than for those continued on intravenous antibiotic orders ($8,684 +/- 4,120 vs. $12,945 +/- 10,204, respectively; p < 0.001). Patients with appendicitis had lower mean hospital costs than those with other infections ($7,169 +/- 3,705 vs. $12,097 +/- 8,342, respectively; p < 0.001). The cost-effectiveness ratios were $14,216:1 for patients in the ciprofloxacin-metronidazole group and $15,398:1 for patients in the piperacillin-tazobactam group. CONCLUSIONS: The mean hospital costs associated with ciprofloxacin-metronidazole were similar to those of piperacillin-tazobactam for the treatment of adults with complicated intra-abdominal infections. Lower costs were documented for patients able to be switched to oral antibiotics and for patients with appendicitis.     

Economic consequences of failure of initial antibiotic therapy in hospitalized adults with complicated intra-abdominal infections

BACKGROUND: Initial antibiotic therapy in hospitalized adults with complicated intra-abdominal infection (cIAI) usually is empiric. We explored the economic consequences of failure of such therapy in this patient population. METHODS: Using a large U.S. multi-institutional database, we identified all hospitalized adults admitted between April 1, 2003, and March 31, 2004; who had any cIAI; underwent laparotomy, laparoscopy, or percutaneous drainage of an intra-abdominal abscess ("surgery"); and received intravenous (IV) antibiotics. Initial therapy was characterized in terms of all IV antibiotics received, on the day of or one day before initial surgery. Antibiotic failure was designated on the basis of the need for reoperation or receipt of other IV antibiotics postoperatively. Switches to narrower spectrum agents and changes in regimen prior to discharge with no other evidence of clinical failure were not counted as antibiotic failures. Using multivariable linear regression, duration of IV antibiotic therapy, hospital length of stay, and total inpatient charges were compared between patients who did and did not fail initial therapy. Mortality was compared using multivariable logistic regression. RESULTS: Among 6,056 patients who met the study entrance criteria, 22.4% failed initial antibiotic therapy. Patients who failed received an additional 5.6 days of IV antibiotic therapy (10.4 total days [95% confidence interval 10.1, 10.8] days vs. 4.8 total days [4.8, 4.9] for those not failing), were hospitalized an additional 4.6 days (11.6 total days [11.3, 11.9] vs. 6.9 total days [6.8, 7.0], respectively), and incurred $6,368 in additional inpatient charges ($16,520 [$16,131, $16,919] vs. $10,152 [$10,027, $10,280]) (all, p < 0.01). They also were more likely to die in the hospital (9.5% vs. 1.3%; multivariable odds ratio 3.58 [95% confidence interval 2.53, 5.06]). CONCLUSIONS: Failure of initial IV antibiotic therapy in hospitalized adults with cIAIs is associated with longer hospitalization, higher hospital charges, and a higher mortality rate.     

Ceftazidime/clindamycin versus tobramycin/clindamycin in the treatment of intra-abdominal infections

In order to assess the efficacy and toxicity of ceftazidime as a substitute for aminoglycosides in the treatment of intra-abdominal sepsis, a prospective randomized trial was conducted. Ninety-four patients (49% trauma) were randomized to receive ceftazidime/clindamycin (CAZ/C) (n = 47) or tobramycin/clindamycin (T/C) (n = 47). CAZ (2.0 gm) and C (0.9 gm) were administered intravenously every 8 hours while T dosage was adjusted to maintain peak (5-8 mg/L) and trough (less than 2 mg/L) concentrations. Age, sex, baseline serum creatinine, and etiology of infection were comparable in the two groups. Clinical cure was similar in culture-positive and culture-negative patients who received CAZ/C (94% vs 88%). The clinical cure rate however was significantly lower in the T/C culture positive (73%) than in the culture negative patients (100%) (P = 0.016). Pathogenic organisms were eradicated in 100% (30/30) and 76% (13/17) of CAZ/C and T/C patients, respectively (P = 0.0006). Nephrotoxicity Nephrotoxicity or ototoxicity was observed in none of the CAZ/C patients and in one and two T/C patients, respectively. CAZ/C more effectively eradicated the bacteria isolated from these patients and no significant difference in clinical response was observed in culture-positive patients. These findings plus the lack of toxicity suggest that CAZ/C is an effective alternative for treatment of IAI.     

Comparison of sequential intravenous/oral ciprofloxacin plus metronidazole with intravenous ceftriaxone plus metronidazole for treatment of complicated intra-abdominal infections

BACKGROUND AND PURPOSE: Intra-abdominal infections are a substantial clinical problem and an important cause of morbidity and death in the hospital. Optimal treatment requires both source control and antibiotic therapy. Sequential intravenous (IV) to oral therapy may improve patient convenience and reduce total health care costs. In this randomized, double-blind trial, the efficacy of sequential IV-to-oral ciprofloxacin plus metronidazole was compared with ceftriaxone plus metronidazole in adult patients with complicated intra-abdominal infections. METHODS: The trial enrolled 531 patients, who began with IV therapy. Patients who improved clinically were switched to oral therapy on day three or later. The clinical and bacteriological responses four to six weeks after the end of therapy and the safety of the two regimens were assessed. To maintain blinding, the patients received placebo IV in the ciprofloxacin group or placebo orally in the ceftriaxone group. A total of 475 patients (235 ciprofloxacin plus metronidazole, 240 ceftriaxone plus metronidazole) were valid for evaluation of efficacy. All patients were included in the safety analysis. RESULTS: Of the patients valid for efficacy, 78% of the ciprofloxacin plus metronidazole group and 81% of the ceftriaxone plus metronidazole group were eligible for a switch to oral therapy. The clinical success rates were 98.9% and 96.9%, respectively, which were statistically equivalent. The clinical success rates for all patients, including those on continuous IV therapy, were 90.6% and 87.9%. Source control was achieved in more than 90% of the patients. The bacteriological eradication rates were similar in the two groups. Bacterial complications (e.g., surgical site infections, abscesses) were encountered more often in the ceftriaxone plus metronidazole group. CONCLUSIONS: Sequential ciprofloxacin plus metronidazole IV-to-oral therapy was statistically equivalent to ceftriaxone plus metronidazole. The switch to oral therapy with ciprofloxacin plus metronidazole was as effective and safe as continued IV therapy in patients able to tolerate enteral feeding.     

Empiric treatment of nosocomial intra-abdominal infections: a focus on the carbapenems

BACKGROUND: Serious nosocomial intra-abdominal infections are associated with high morbidity and mortality and represent a substantial drain on healthcare resources. Effective management of this type of infection requires the early use of appropriate, broad-spectrum empiric antimicrobial therapy. The consequences of delayed or inappropriate antimicrobial treatment can be severe-leading to an increased risk of death, re-operation, or prolonged hospitalization. Therefore, it is necessary to begin treatment as soon as possible with the most appropriate regimen, in terms of spectrum, timing, and duration. METHODS: Review of pertinent English-language literature. RESULTS: Serious nosocomial intra-abdominal infections require broad-spectrum coverage because of the wide range of possible pathogens, which include difficult-to-treat organisms such as Pseudomonas aeruginosa and Bacteroides spp., and resistant strains of Klebsiella spp., Escherichia coli, and methicillin-resistant Staphylococcus aureus acquired from the hospital flora. The early use of appropriate, broad-spectrum empiric antimicrobial therapy for treating high-risk patients with intra-abdominal infections is considered, and appropriate use of the carbapenems, meropenem, and imipenem/cilastatin, is described. CONCLUSION: The carbapenems meropenem and imipenem/cilastatin have a spectrum of antimicrobial activity that covers the majority of expected pathogens, including anaerobes, as well as difficult-to-treat and resistant gram-negative strains. Early and appropriate use can reduce mortality and morbidity. Data from published clinical trials support the clinical effectiveness of these two carbapenems in intra-abdominal infections.     

Apalcillin treatment of complicated urinary tract infections

In an open, prospective clinical trial, we evaluated the safety and efficacy of apalcillin in the treatment of complicated urinary tract infection. 21 hospitalized adult patients received apalcillin 2 g IV Q8-12 h for 5-17 days. There were 8 upper tract and 13 lower tract infections. Of 25 functional or anatomic abnormalities of the GU tract among these patients, 9 (36%) were corrected during the study period. Effectiveness of apalcillin was determined by clinical and bacteriologic response. 16 (76.2%) patients had clinical cures, 4 (19.8%) had clinical improvement, and 1 (4.8%) had clinical failure. Based on 26 pretreatment isolates, there were 16 (61.5%) bacteriologic cures and 10 (38.5%) failures. Failures were due to 6 (23.1%) relapses, 2 (7.7%) superinfections, and 2 (7.7%) relapses with superinfection. Adverse reactions were mild, transient, and did not require discontinuation of treatment. Apalcillin appears to be a safe, although marginally effective single agent antibiotic for the treatment of complicated urinary tract infections.     

Ertapenem or ticarcillin/clavulanate for the treatment of intra-abdominal infections or acute pelvic infections in pediatric patients

BACKGROUND: Ertapenem, a group I carbapenem antibiotic, has been shown to be safe and effective in treating adults with complicated intra-abdominal (cIAI) or acute pelvic infection (API). This study evaluated ertapenem for treating these infections in children. METHODS: In an open-label study, children aged 2 to 17 years with cIAI or API were randomized 3:1 to receive ertapenem or ticarcillin/clavulanate. Children 13 to 17 years of age received 1 g parenterally daily, and those 2 to 12 years of age received 15 mg/kg twice daily. Patients < 60 kg received ticarcillin/clavulanate 50 mg/kg 4 to 6 times daily and 3.1 g 4 to 6 times daily for those > or = 60 kg. Patients were assessed for safety and tolerability throughout the study and for efficacy after the completion of therapy. RESULTS: One hundred five patients, 72 (69%) with cIAI, received > or = 1 dose of study drug and were included in the safety analysis. Eighty-one patients were treated with ertapenem. Infusion site pain was the most common drug-related adverse event in both groups. In the modified intent-to-treat analysis, the age-adjusted posttreatment clinical response rates were 87% (43/50 patients) and 100% (25/25 patients) in the cIAI and API patients, respectively, for ertapenem and 73% (11/15 evaluable patients) and 100% (8/8 evaluable patients), respectively, for ticarcillin/clavulanate. Overall age-adjusted response rates were 91% (68/75 evaluable patients) for ertapenem and 83% (19/23 evaluable patients) for the comparator. CONCLUSIONS: This study suggests that ertapenem is generally safe and efficacious for treating cIAI or API in pediatric patients.     

Treatment of intra-abdominal infections is appropriate with single-agent or combination antibiotic therapy

In a prospective, randomized, single-blind trial, we studied 112 adults with intra-abdominal infections and compared antibiotic therapy with cefoxitin plus placebo to therapy with tobramycin plus clindamycin. Seventy-five percent of patients receiving tobramycin-clindamycin and 71% of those receiving cefoxitin-placebo had either shock, bacteremia, malnutrition, alcoholism, rapidly or ultimately fatal underlying disease, infection originating from the distal small bowel or colon, or had had failed therapy before treatment ("high-risk" group). One third of the patients in both groups grew bacteria in the initial culture resistant to the antibiotic regimen used. Ten patients receiving cefoxitin-placebo (17%) and 11 receiving tobramycin-clindamycin (21%) had recurrence of infection or died of infection (clinical failures). Nineteen failures occurred in high-risk patients (p less than 0.05) and 17 were in patients that had antibiotic-resistant bacteria in the initial culture (p less than 0.01). Adverse effects were rare and remitted after antibiotics were stopped. Our results suggest that both cefoxitin and tobramycin-clindamycin are appropriate antibiotic regimens to treat intra-abdominal infections. Clinical failure is more common in high-risk patients and when antibiotic-resistant organisms are isolated from initial cultures.     

克罗恩病并发腹腔脓肿的临床特征与外科治疗

目的探讨克罗恩病(CD)合并腹腔脓肿的临床特征和外科治疗及预后。方法对2000-2005年间收治的142例CD患者其中合并腹腔脓肿的39例临床资料进行总结分析。结果本组CD患者合并腹腔脓肿的总发病率为27.5%,从发病到脓肿形成的时间范围为0-22年,平均5年。发病年龄(34.7±12.3)岁。24例(61.5%)患者既往有手术史;30例(76.9%)患者的脓肿发生在右侧腹,尤其是在吻合口附近(48.7%)。36例(92.3%)采取手术治疗,其中34例(34/36,94.4%)行手术引流加病变肠管切除,恢复良好。结论CD有较高的腹腔脓肿并发率,发病年龄多在35岁,将近50%发生在原吻合口;脓肿前的CD病程平均5年;手术方式以脓肿引流加病变肠管切除为主。