Imipenem (N-F-thienamycin) versus netilmicin plus clindamycin. A controlled and randomized comparison in intra-abdominal infections

In a randomized study the clinical and bacteriologic effectiveness of imipenem was compared with the classical combination of netilmicin with clindamycin in patients who had surgery for an intraperitoneal infection, localized or generalized, with positive bacteriologic findings of the specimen taken at surgery. Excluded were all patients who received other antibiotics before surgery, or who died within 3 days after antibiotic therapy was started. Imipenem was given at a dose of 500 mg t.i.d., clindamycin 600 mg t.i.d., and netilmicin according to serum levels. The diagnoses ranged from postoperative peritonitis, gallbladder empyema, perforated gastroduodenal ulcer, small bowel perforation with and without obstruction, and perforated appendicitis to perforation of the colon. The bacteriologic work-up included examination of the primary specimen (aerobic and anaerobic), the urine, feces, and serologic testing for Candida albicans once or twice a week and after the course of antibiotic therapy. In addition, pH measurements of abscesses and drainage fluids were performed. Ninety-three patients entered the study. Forty-seven patients were treated with imipenem (test group), and 46 patients were treated with the combination therapy (control group). The two groups did not show significant differences in age, sex, diagnostic groups, risk factors, primary bacteriology, and duration of therapy (mean: 6.7 days). Thirty-eight patients (80.9%) treated with imipenem were cured, six patients (12.8%) were improved, and there were three (6.4%) failures. The respective numbers for the control group were 31 (67.4%), 10 (21.7%), and 5 (10.9%). The mean duration of hospitalization was 19 days for the test group and 24.5 days for the control group. There were four wound infections in the test group and 11 wound infections in the control group. Imipenem is at least as effective in the adjuvant therapy of intra-abdominal infections as the combination of netilmicin with clindamycin.     

Seltene Verletzung bei stumpfem Bauchtrauma im Kindesalter

Presented in this work is a rare injury of a blunt abdominal trauma in a child. Besides a partial rupture of the kidney and a retro-/intraperitoneal haematoma, a further injury occurred from the accident: an initially clinically indetectable tear of the A. iliaca communis which was found intraoperatively and with systematic CT analysis. Traumatic blood vessel lesions of the abdominal aorta and in particular the iliac blood vessels are very rare in children. By such violent impact injuries, it is therefore vital to perform a clinical examination of the foot pulse, systematic analysis of radiology diagnostics, and intraoperative exploration. The growth phase should be considered for therapy of the blood vessels depending on the child's age group. As the long-term results of graft implants are practically unknown, if possible a primary suture or vein patch should be performed.     

Follow-up of abdominal surgery by analysis of pH, p02 and pCO2 in drainage fluid]

Milieu factors such as pH, pO2, and pCO2 have previously been shown to permit reliable intraoperative discrimination of infected and non-infected peritoneal or drainage fluid. The presence of infection was associated with pH less than 7.1, pO2 less than 6.5 kPa and pCO2 greater than 8 kPa. These variables were monitored in the immediate postoperative period to quantify clinical improvement and to evaluate their potential for the early detection of infective complications. 21 patients underwent laparotomy for intraabdominal infections such as perforated appendicitis or perforated sigmoid diverticulitis. 5 were operated on for reasons other than infection. Fluid was sampled from a drainage tube every second day for a mean period of 7 days for determination of pH, pO2, and pCO2. A score ranging from 0 (normal) to 6 (severely ill) was calculated from these measurements. Specimens were obtained intraoperatively from 14 patients with documented infections and their mean score averaged 5 (range 3-6). Specimens were obtained on days 4 and 6 from 18 patients whose progress was uneventful and their mean score was 0.3 (range 0-2). 4 of these 26 patients developed postoperative infections after anastomotic breakdown, and each of their scores increased 1-2 days before the infection became clinically obvious, reaching values ranging from 3-6. In contrast, only 1 of 18 patients who made uneventful progress scored greater than 2 after day 3 (p less than 0.01). We conclude that assessment of milieu factors in peritoneal or drainage fluid permits quick and easy monitoring of the postoperative course.