Intra-abdominal infections (IAIs) account for a major cause of morbidity and mortality, representing the second most common sepsis-related death with a hospital mortality of 23-38%. Prompt identification of sepsis source, appropriate resuscitation, and early treatment with the shortest delay possible are the cornerstones of management of IAIs and are associated with a more favorable clinical outcome. The aim of source control is to reduce microbial load by removing the infection source and it is achievable by using a wide range of procedures, such as definitive surgical removal of anatomic infectious foci, percutaneous drainage and toilette of infected collections, decompression, and debridement of infected and necrotic tissue or device removal, providing for the restoration of anatomy and function. Damage control surgery may be an option in selected septic patients. Intra-abdominal infections can be classified as uncomplicated or complicated causing localized or diffuse peritonitis. Early clinical evaluation is mandatory in order to optimize diagnostic testing and establish a therapeutic plan. Prognostic scores could serve as helpful tools in medical settings for evaluating both the seriousness and future outlook of a condition. The patient\'s conditions and the potential progression of the disease determine when to initiate source control. Patients can be classified into three groups based on disease severity, the origin of infection, and the patient\'s overall physical health, as well as any existing comorbidities. In recent decades, antibiotic resistance has become a global health threat caused by inappropriate antibiotic regimens, inadequate control measures, and infection prevention. The sepsis prevention and infection control protocols combined with optimizing antibiotic administration are crucial to improve outcome and should be encouraged in surgical departments. Antibiotic and antifungal regimens in patients with IAIs should be based on the resistance epidemiology, clinical conditions, and risk for multidrug resistance (MDR) and Candida spp. infections. Several challenges still exist regarding the effectiveness, timing, and patient stratification, as well as the procedures for source control. Antibiotic choice, optimal dosing, and duration of therapy are essential to achieve the best treatment. Promoting standard of care in the management of IAIs improves clinical outcomes worldwide. Further trials and stronger evidence are required to achieve optimal management with the least morbidity in the clinical care of critically ill patients with intra-abdominal sepsis.

Intra-abdominal infections (IAIs) are common surgical emergencies and are an important cause of morbidity and mortality in hospital settings, particularly if poorly managed. The cornerstones of effective IAIs management include early diagnosis, adequate source control, appropriate antimicrobial therapy, and early physiologic stabilization using intravenous fluids and vasopressor agents in critically ill patients. Adequate empiric antimicrobial therapy in patients with IAIs is of paramount importance because inappropriate antimicrobial therapy is associated with poor outcomes. Optimizing antimicrobial prescriptions improves treatment effectiveness, increases patients\' safety, and minimizes the risk of opportunistic infections (such as Clostridioides difficile) and antimicrobial resistance selection. The growing emergence of multi-drug resistant organisms has caused an impending crisis with alarming implications, especially regarding Gram-negative bacteria. The Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use promoted a consensus conference on the antimicrobial management of IAIs, including emergency medicine specialists, radiologists, surgeons, intensivists, infectious disease specialists, clinical pharmacologists, hospital pharmacists, microbiologists and public health specialists. Relevant clinical questions were constructed by the Organizational Committee in order to investigate the topic. The expert panel produced recommendation statements based on the best scientific evidence from PubMed and EMBASE Library and experts\' opinions. The statements were planned and graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence. On November 10, 2023, the experts met in Mestre (Italy) to debate the statements. After the approval of the statements, the expert panel met via email and virtual meetings to prepare and revise the definitive document. This document represents the executive summary of the consensus conference and comprises three sections. The first section focuses on the general principles of diagnosis and treatment of IAIs. The second section provides twenty-three evidence-based recommendations for the antimicrobial therapy of IAIs. The third section presents eight clinical diagnostic-therapeutic pathways for the most common IAIs. The document has been endorsed by the Italian Society of Surgery.

Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient\'s clinical condition, and the host\'s immune status should be assessed continuously to optimize the management of patients with complicated IAIs.

Background: Candida species account for approximately 15% of hospital-associated infections, causing fatal consequences, especially in critically ill patients. This study aimed to evaluate invasive candidiasis (IC) risk factors in critically ill patients undergoing surgery. Patients and Methods: We retrospectively reviewed the medical records of 583 patients who underwent emergency surgery for complicated intra-abdominal infections between January 2016 and December 2021. Patients were divided into two groups according to the presence or absence of IC during their hospital stay. IC was defined as culture-proven candidemia and intra-abdominal candidiasis. Results: This study included 373 patients for the final analysis, of whom 320 were discharged without IC (IC absent group) and 53 presented with IC (IC present group) during their hospital stay. The IC present group showed a higher in-hospital mortality rate (35.8 vs. 8.8%; p < 0.001), with 66.0% of the patients diagnosed within 10 days, whereas only 6.5% were diagnosed beyond 20 days after admission. Stomach (odds ratio [OR], 4.188; 95% confidence interval [CI], 1.204-14.561; p = 0.024) and duodenum (OR, 7.595; 95% CI, 1.934-29.832; p = 0.004) as infection origin, higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score (OR, 1.097; 95% CI, 1.044-1.152; p < 0.001), and lower initial systolic blood pressure (OR, 0.983; 95% CI, 0.968-0.997; p = 0.018) were risk factors of IC after emergency gastrointestinal surgery. Conclusions: Patients who had stomach and duodenum as infection origin, higher APACHE II scores, and lower initial systolic blood pressure had a higher risk of developing IC during their hospital stay after emergency gastrointestinal surgery. Prophylactic antifungal agents can be carefully considered for critically ill patients with these features.

Klebsiella pneumoniae is a common causative pathogen of intra-abdominal infection with concomitant bacteraemia, leading to a significant mortality risk. The time to positivity (TTP) of blood culture is postulated to be a prognostic factor in bacteraemia caused by other species. Therefore, this study aimed to investigate the prognostic value of TTP in these patients. The single-centred, retrospective, observational cohort study was conducted between 1 July 2016 and 30 June 2021. All adult emergency department patients with diagnosis of intra-abdominal infection and underwent blood culture collection which yield K. pneumoniae during this period were enrolled. A total of 196 patients were included in the study. The overall 30-day mortality rate was 12.2% (24/196), and the median TTP of the studied cohort was 12.3 h (10.5-15.8 h). TTP revealed a moderate 30-day mortality discriminative ability (area under the curve 0.73, p < 0.001). Compared with the late TTP group (>12 h, N = 109), patients in the early TTP (≤12 h, N = 87) group had a significantly higher risk of 30-day morality (21.8% vs. 4.6%, p < 0.01) and other adverse outcomes. Furthermore, TTP (odds ratio [OR] = 0.79, p = 0.02), Pitt bacteraemia score (OR = 1.30, p = 0.03), and implementation of source control (OR = 0.06, p < 0.01) were identified as independent factors related to 30-day mortality risk in patients with intra-abdominal infection and K. pneumoniae bacteraemia. Therefore, physicians can use TTP for prognosis stratification in these patients.

Background Liver abscesses are a significant health concern, necessitating prompt diagnosis and appropriate management. Spontaneous liver abscesses are a frequent reason for hospitalizations in India, particularly in the northern part. By analyzing demographics, symptoms, radiological findings, laboratory parameters, and treatment outcomes, this study will contribute valuable insights to enhance the understanding and management of liver abscesses. Aims and objective To evaluate demographic, clinical, laboratory, and radiological parameters and management options in hospitalized patients with liver abscesses at a tertiary care center. Methods This study retrospectively analyzed prospectively collected data from 150 patients diagnosed with liver abscesses who were admitted to our ward for one year. Data on demographic characteristics, clinical presentation, etiology, radiological findings, laboratory investigations, management strategies, and treatment outcomes were collected. Descriptive statistics and relevant statistical tests were employed for data analysis. Results The study population had a mean age of 40.28±12.72 years, with a male preponderance (136 (90.7%)). Amoebic abscesses (94 (62.7%)) were the most common. Hepatomegaly (144 (96%)), fever (140 (93.3%)), abdominal pain (136 (90.7%)), and anorexia (118 (78.7%)) were the most common symptoms. Ultrasonography revealed solitary abscesses (99 (66%)) to be more common than multiple abscesses (24 (16%)), with a predominant location in the right lobe (128 (85.3%)). Laboratory investigations showed leukocytosis in 121 (80.7%), elevated liver enzymes (95 (63.3%) aspartate aminotransferase (AST) and 80 (53.3%) alanine transaminase (ALT)), elevated alkaline phosphatase (ALP) in 133 (88.7%), and low albumin levels (138 (92%)) in a significant proportion of patients. Single-time needle aspiration (95 (63.3%)), percutaneous drain (36 (24%)), and surgical intervention (4 (2.7%)) were the primary treatment modalities. Serum albumin level (p<0.001) and ALP (p<0.001) were significantly low and high, respectively, in patients with hospital stays ≥10 days. Conclusions This study provides insights into patients with liver abscesses\' clinical and laboratory parameters and management strategies. The findings highlight the diverse clinical presentation, varied etiologies, and the importance of radiological imaging and laboratory investigations in diagnosis and management. Tailored treatment strategies based on the patient\'s condition are crucial for optimizing outcomes.

Background: The urea to albumin ratio (UAR) has shown a prognostic value in various clinical settings, however, no study has yet investigated its ability to predict outcome in complicated intra-abdominal infections (cIAIs). Therefore, our aim was to evaluate the association between UAR and mortality in such patients. Patients and Methods: A single-center prospective study including 62 patients with cIAIs was performed at a University Hospital Stara Zagora for the period November 2018 to August 2021. Various routine laboratory and clinical parameters were recorded before surgery and on post-operative day 3. We used serum levels of urea and albumin to calculate the UAR. Results: The observed in-hospital mortality was 14.5%. Non-survivors had higher pre- and post-operative median of UAR than survivors (88.39 vs. 30.99, p < 0.0001 and 106.18 vs. 26.58, p < 0.0001, respectively). Lethal outcome was predicted successfully both by UAR before surgery (area under receiver operating characteristics [AUROC] curves = 0.889; p < 0.0001) at a threshold of 61.42 and on third post-operative day (AUROC = 0.943; p < 0.0001) at a threshold = 55.89. Conclusions: Peri-operative UAR showed an excellent ability for prognostication of fatal outcome in patients with cIAIs.

UNASSIGNED: Elderly patients with intra-abdominal infection are more vulnerable to sepsis progression, especially in those who had concomitant bacteremia. The time to positivity (TTP) of blood cultures in patients with bacteremia is considered to be a prognostic factor for some bacterial species. This study aimed to investigate the prognostic value of TTP in elderly patients with intra-abdominal infection and Klebsiella pneumoniae bacteremia.
UNASSIGNED: A retrospective observational, case-control study was conducted at a single tertiary referral medical center. All elderly (aged ≥ 65 years) patients diagnosed with intra-abdominal infection and Klebsiella pneumoniae bacteremia in the emergency department between July 1, 2016, and June 30, 2021 were enrolled. The baseline characteristics, TTP of blood cultures, management strategy, and outcomes of each eligible patient were recorded and analyzed. The primary outcome was to examine the association between TTP and the 30-day mortality risk in enrolled patients.
UNASSIGNED: A total of 101 patients were included in the study. The overall 30-day mortality rate was 11.9% (12/101). The median TTP of Klebsiella pneumoniae in the eligible patients was 12.5 (11-16) hours. There was a stepwise significantly decreased mortality rate as TTP increased (p = 0.04). The TTP had a moderate mortality discrimination ability (area under receiver operating characteristic curve = 0.75, 95% CI = 0.65-0.83, p < 0.01). Furthermore, the Pittsburg bacteremia score (hazard ratio [HR] = 2.19, p < 0.01) and TTP (HR = 0.82, p = 0.04) were identified as independent factors associated with 30-day mortality.
UNASSIGNED: TTP was associated with 30-day mortality risk in elderly patients with Klebsiella pneumoniae bacteremia and intra-abdominal infection. Clinicians can utilize TTP for risk stratification, and initiate prompt treatment in those patients with shorter TTP.

Background: Intra-abdominal candidiasis (IAC) is associated with substantial morbidity and mortality in hospitalized patients. Identifying high-risk populations may facilitate early and selective directed therapy in appropriate patients and avoid unwarranted treatment and any associated adverse effects in those who are low risk. Patients and Methods: This retrospective, case-control study included patients >18 years of age admitted from July 1, 2010 to July 1, 2021 who had a microbiologically confirmed intra-abdominal infection (gastrointestinal culture positive for either a Candida spp. [cases] or bacterial isolate [controls] collected intra-operatively or from a drain placed within 24 hours). Patients receiving peritoneal dialysis treatment or with a peritoneal dialysis catheter in place or treated at an outside hospital were excluded. Multivariable regression was utilized to identify independent risk factors for the development of IAC. Results: Five hundred twenty-three patients were screened, and 250 met inclusion criteria (125 per cohort). Multivariable analysis identified exposure to corticosteroids (odds ratio [OR], 5.79; 95% confidence interval [CI], 2.52-13.32; p < 0.0001), upper gastrointestinal tract surgery (OR, 3.51; 95% CI, 1.25-9.87; p = 0.017), and mechanical ventilation (OR, 3.09; 95% CI 1.5-6.37; p = 0.002) were independently associated with IAC. The area under the receiver operating characteristic (AUROC) and goodness of fit were 0.7813 and p = 0.5024, respectively. Conclusions: Exposure to corticosteroids, upper gastrointestinal tract surgery, and mechanical ventilation are independent risk factors for the development of microbiologically confirmed IAC suggesting these factors may help identify high-risk individuals requiring antifungal therapy.

UNASSIGNED: Post-operative infection is a common complication following abdominal surgery. The two most common infections are secondary peritonitis and surgical site infections, which lead to increased perioperative morbidity, prolonged hospitalization, higher mortality rates, and increased treatment costs. In addition to surgical procedures, treatment is based on effective antibiotic therapy. Due to increasing antimicrobial resistance, the correct use of antimicrobials is becoming more complex. Many initiatives call for the implementation of an antimicrobial stewardship (AMS) programme to optimize anti-infective therapy. The review article summarizes current recommendations in anti-infective therapy of post-operative peritonitis and surgical site infections and highlights the importance of an AMS programme in abdominal surgery.
UNASSIGNED: Larger studies evaluating the benefit of AMS in abdominal surgery are lacking. However, national and international guidelines have formulated appropriate recommendations for the rational use of antibiotics in post-operative peritonitis and surgical site infections. The rate of post-operative infections can be significantly reduced by perioperative antibiotic prophylaxis. The increase in multidrug-resistant bacteria complicates anti-infective therapy for post-operative infections. Analysis of local susceptibility patterns helps choose an adequate empiric therapy. A high rate of extended-spectrum beta-lactamase-producing bacteria may necessitate the use of other reserve antibiotics in addition to carbapenems, which are approved for the treatment of complicated intra-abdominal infections. A key role for the AMS team is the subsequent de-escalation of antibiotic therapy which limits the use of unnecessary broad-spectrum antibiotics.
UNASSIGNED: The increase in multidrug-resistant bacteria poses challenges for abdominal surgery. Post-operative infections should be treated by an interdisciplinary team of surgeons and specialists for AMS.