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Intraperitoneal infection (IAI) is one of the most common clinical acute and critical illnesses, with a high morbidity and fatality rate.
Postoperative abdominal infection (PIAI) is an important type of IAI, which is a hospital-acquired abdominal infection.
PIAI faces many challenges such as drug-resistant infections, chronic critical illness (CCI), abdominal hypertension (IAH), and multiple organ dysfunction.
Early diagnosis and timely and effective treatment are essential.
1 The definition of PIAI PIAI refers to the clinical manifestations of IAI within 30 days after surgery or operation, and laboratory examinations and imaging studies confirm the presence of IAI or drainage fluid confirms the presence of abdominal abscess.
2 PIAI risk factors PIAI can be affected by a variety of risk factors.
Identifying risk factors that can be avoided during the perioperative period can reduce the incidence of PIAI.
The risk factors of PIAI during the perioperative period include: heart, liver, kidney and other organ dysfunction, diabetes or other underlying diseases, hypoproteinemia (<35 g/L), anemia, intestinal obstruction, American Association of Anesthesiologists (ASA) Score>3, malnutrition, malignant tumor, advanced age, use of corticosteroids, long operation time, peritoneal lavage that contaminates the abdominal cavity, use of laparoscopy or stapler, combined organ resection, blood transfusion, massive intraoperative blood loss and postoperative Stoma, anastomotic leakage, postoperative drainage tube indwelling time is long.
3PIAI Early Diagnosis The diagnosis of PIAI mainly includes medical history, physical examination, laboratory examination, imaging examination and abdominal puncture.
Continuous increase in abdominal pressure or new IAH after operation is an important sign of PIAI.
It is recommended that all critically ill patients after abdominal operation should routinely monitor intra-abdominal pressure (IAP).
If the patient has unexplained tachycardia or shortness of breath after surgery, it may indicate infection; low blood pressure may even indicate a critical condition, requiring urgent intervention and analysis of the cause.
Patients with indwelling drainage tube after operation have observed purulent secretions in the drainage tube, which is also helpful for the diagnosis of IAI.
The 2019 IAI diagnosis and treatment guidelines strongly recommend the use of laboratory tests, serum procalcitonin (PCT) and C-reactive protein (CRP) for auxiliary examinations when IAI is suspected, which can assist in the early diagnosis of IAI.
For high-risk patients with PIAI, the infection markers can be tested continuously for many times to diagnose PIAI early.
Perform imaging examinations in time, and CT and ultrasound examinations are recommended to confirm the diagnosis.
4 PIAI treatment PIAI can cause intestinal endotoxemia and further progress to multiple organ failure (MODS).
Therefore, on the basis of early diagnosis, comprehensive treatment measures for IAI should be emphasized.
The current domestic and foreign treatment measures for IAI mainly include the following aspects: ① infection source control; ② microbiological examination; ③ anti-infective treatment; ④ nutritional therapy; ⑤ organ function support.
➤Control of the source of infection For PIAI, the control of the source of infection should be initiated as soon as possible.
It is recommended to control the infection within 24 hours after the diagnosis is confirmed, unless it is clinically prompted that non-invasive operation or delayed source of infection control is applicable.
Adequately drain the infectious fluid (exudation or pus) in the abdominal cavity, remove the necrotic infected tissue, and prevent IAI patients from being continuously contaminated.
Specific methods include definitive surgery, surgery to avoid continued contamination, surgical treatment for the purpose of debridement and drainage, puncture drainage, and open abdominal therapy.
➤Microbiological examination PIAI patients routinely culture aerobic bacteria and anaerobic bacteria in the abdominal cavity to identify potential drug-resistant or opportunistic pathogens; patients with sepsis or immunosuppression should undergo blood culture to confirm the diagnosis of bacteremia Exist; if necessary, fungal blood culture is feasible.
➤Anti-infective treatment When conditions permit, when IAI progresses to sepsis, empirical anti-infective treatment should be started within 1 h after diagnosis, and early anti-infective treatment should be emphasized in other cases.
For PIAI patients, the recommended single-drug regimen is imipenem-cilastatin, meropenem and other carbapenems, and the combined regimen is cefepime, ceftazidime and other third-generation cephalosporins combined with nitroimidazole drugs .
It is recommended that the down-stair treatment is guided by the results of microbiology and drug sensitivity.
The course of anti-infective treatment is generally 7-10 days.
➤Nutrition treatment Enteral nutrition is an important treatment measure for PIAI, but the timing is more important, and it is necessary to comprehensively evaluate the gastrointestinal function and the control of infection sources.
PIAI patients often have different degrees of gastrointestinal dysfunction.
Enteral nutrition cannot be implemented before the intestinal function is restored.
At this time, the energy and protein supply of PIAI patients should be maintained through parenteral nutrition.
After the intestinal function is restored, it is necessary to evaluate the control of the source of infection to determine whether enteral nutrition can be implemented.
If the source of infection has not been controlled, such as the leakage of digestive juice into the abdominal cavity without sufficient drainage, enteral nutrition is used at this time It will increase the leakage of digestive juices, which will aggravate abdominal infections.
Therefore, choosing the right time to resume enteral nutrition as soon as possible will help improve the success rate of PIAI treatment.
➤Organ function support During the treatment of PIAI, attention should be paid to organ dysfunction caused by infection, and corresponding supportive treatment measures should be taken, including circulatory and respiratory support, artificial liver support, and continuous renal replacement therapy.
References: 1.
Wang Gefei, Ren Jianan, Li Jieshou.
Postoperative abdominal infection challenges and treatment strategies.
Chinese Journal of Practical Surgery.
2021,41(3):348-392.
2.
Im-Kyung Kim, Jae Gil Lee.
Antibiotic duration can be shortened in postoperative intra-abdominal infection.
J Thorac Dis.
2018 Sep;10(Suppl 26):S3182-S3183.
3.
Surgery Branch of Chinese Medical Association, Evidence-based and Transformation Professional Committee of Infectious Diseases of Chinese Research Hospital Association, Editorial Department of Chinese Journal of Surgery.
Expert consensus on multidisciplinary diagnosis and treatment of common abdominal infections in surgery [J].
Chinese Journal of Surgery.
2021,59(3): 161-1784.
Surgery Infection and Critical Care Medicine Group of the Chinese Medical Association Surgery Branch, Professional Committee of Intestinal Fistula Surgeons of the Chinese Medical Association Surgery Branch.
Guidelines for the diagnosis and treatment of abdominal infections in China ( (2019 edition) [J].
Chinese Journal of Practical Surgery, 2020, 40(1): 1-16.
Intraperitoneal infection (IAI) is one of the most common clinical acute and critical illnesses, with a high morbidity and fatality rate.
Postoperative abdominal infection (PIAI) is an important type of IAI, which is a hospital-acquired abdominal infection.
PIAI faces many challenges such as drug-resistant infections, chronic critical illness (CCI), abdominal hypertension (IAH), and multiple organ dysfunction.
Early diagnosis and timely and effective treatment are essential.
1 The definition of PIAI PIAI refers to the clinical manifestations of IAI within 30 days after surgery or operation, and laboratory examinations and imaging studies confirm the presence of IAI or drainage fluid confirms the presence of abdominal abscess.
2 PIAI risk factors PIAI can be affected by a variety of risk factors.
Identifying risk factors that can be avoided during the perioperative period can reduce the incidence of PIAI.
The risk factors of PIAI during the perioperative period include: heart, liver, kidney and other organ dysfunction, diabetes or other underlying diseases, hypoproteinemia (<35 g/L), anemia, intestinal obstruction, American Association of Anesthesiologists (ASA) Score>3, malnutrition, malignant tumor, advanced age, use of corticosteroids, long operation time, peritoneal lavage that contaminates the abdominal cavity, use of laparoscopy or stapler, combined organ resection, blood transfusion, massive intraoperative blood loss and postoperative Stoma, anastomotic leakage, postoperative drainage tube indwelling time is long.
3PIAI Early Diagnosis The diagnosis of PIAI mainly includes medical history, physical examination, laboratory examination, imaging examination and abdominal puncture.
Continuous increase in abdominal pressure or new IAH after operation is an important sign of PIAI.
It is recommended that all critically ill patients after abdominal operation should routinely monitor intra-abdominal pressure (IAP).
If the patient has unexplained tachycardia or shortness of breath after surgery, it may indicate infection; low blood pressure may even indicate a critical condition, requiring urgent intervention and analysis of the cause.
Patients with indwelling drainage tube after operation have observed purulent secretions in the drainage tube, which is also helpful for the diagnosis of IAI.
The 2019 IAI diagnosis and treatment guidelines strongly recommend the use of laboratory tests, serum procalcitonin (PCT) and C-reactive protein (CRP) for auxiliary examinations when IAI is suspected, which can assist in the early diagnosis of IAI.
For high-risk patients with PIAI, the infection markers can be tested continuously for many times to diagnose PIAI early.
Perform imaging examinations in time, and CT and ultrasound examinations are recommended to confirm the diagnosis.
4 PIAI treatment PIAI can cause intestinal endotoxemia and further progress to multiple organ failure (MODS).
Therefore, on the basis of early diagnosis, comprehensive treatment measures for IAI should be emphasized.
The current domestic and foreign treatment measures for IAI mainly include the following aspects: ① infection source control; ② microbiological examination; ③ anti-infective treatment; ④ nutritional therapy; ⑤ organ function support.
➤Control of the source of infection For PIAI, the control of the source of infection should be initiated as soon as possible.
It is recommended to control the infection within 24 hours after the diagnosis is confirmed, unless it is clinically prompted that non-invasive operation or delayed source of infection control is applicable.
Adequately drain the infectious fluid (exudation or pus) in the abdominal cavity, remove the necrotic infected tissue, and prevent IAI patients from being continuously contaminated.
Specific methods include definitive surgery, surgery to avoid continued contamination, surgical treatment for the purpose of debridement and drainage, puncture drainage, and open abdominal therapy.
➤Microbiological examination PIAI patients routinely culture aerobic bacteria and anaerobic bacteria in the abdominal cavity to identify potential drug-resistant or opportunistic pathogens; patients with sepsis or immunosuppression should undergo blood culture to confirm the diagnosis of bacteremia Exist; if necessary, fungal blood culture is feasible.
➤Anti-infective treatment When conditions permit, when IAI progresses to sepsis, empirical anti-infective treatment should be started within 1 h after diagnosis, and early anti-infective treatment should be emphasized in other cases.
For PIAI patients, the recommended single-drug regimen is imipenem-cilastatin, meropenem and other carbapenems, and the combined regimen is cefepime, ceftazidime and other third-generation cephalosporins combined with nitroimidazole drugs .
It is recommended that the down-stair treatment is guided by the results of microbiology and drug sensitivity.
The course of anti-infective treatment is generally 7-10 days.
➤Nutrition treatment Enteral nutrition is an important treatment measure for PIAI, but the timing is more important, and it is necessary to comprehensively evaluate the gastrointestinal function and the control of infection sources.
PIAI patients often have different degrees of gastrointestinal dysfunction.
Enteral nutrition cannot be implemented before the intestinal function is restored.
At this time, the energy and protein supply of PIAI patients should be maintained through parenteral nutrition.
After the intestinal function is restored, it is necessary to evaluate the control of the source of infection to determine whether enteral nutrition can be implemented.
If the source of infection has not been controlled, such as the leakage of digestive juice into the abdominal cavity without sufficient drainage, enteral nutrition is used at this time It will increase the leakage of digestive juices, which will aggravate abdominal infections.
Therefore, choosing the right time to resume enteral nutrition as soon as possible will help improve the success rate of PIAI treatment.
➤Organ function support During the treatment of PIAI, attention should be paid to organ dysfunction caused by infection, and corresponding supportive treatment measures should be taken, including circulatory and respiratory support, artificial liver support, and continuous renal replacement therapy.
References: 1.
Wang Gefei, Ren Jianan, Li Jieshou.
Postoperative abdominal infection challenges and treatment strategies.
Chinese Journal of Practical Surgery.
2021,41(3):348-392.
2.
Im-Kyung Kim, Jae Gil Lee.
Antibiotic duration can be shortened in postoperative intra-abdominal infection.
J Thorac Dis.
2018 Sep;10(Suppl 26):S3182-S3183.
3.
Surgery Branch of Chinese Medical Association, Evidence-based and Transformation Professional Committee of Infectious Diseases of Chinese Research Hospital Association, Editorial Department of Chinese Journal of Surgery.
Expert consensus on multidisciplinary diagnosis and treatment of common abdominal infections in surgery [J].
Chinese Journal of Surgery.
2021,59(3): 161-1784.
Surgery Infection and Critical Care Medicine Group of the Chinese Medical Association Surgery Branch, Professional Committee of Intestinal Fistula Surgeons of the Chinese Medical Association Surgery Branch.
Guidelines for the diagnosis and treatment of abdominal infections in China ( (2019 edition) [J].
Chinese Journal of Practical Surgery, 2020, 40(1): 1-16.
