Pieracci Fredric M, Barie Philip S
Department of Surgery and Public Health, Weill Medical College of Cornell University, New York, New York, USA.
Curr Opin Crit Care. 2007 Aug;13(4):440-9. doi: 10.1097/MCC.0b013e32825a6720.
The aim of this article is to outline developments in the three cornerstones of treatment of intra-abdominal infections during critical illness: source control; antimicrobial therapy; and mitigation of deranged immune and coagulation responses.
Although adequate source control remains the goal of mechanical management of intra-abdominal infections, neither planned re-laparotomy nor open-abdomen management appears to offer a survival benefit as compared with on-demand re-laparotomy. Novel approaches to restoration of a functional gastrointestinal tract have emerged as alternatives to more invasive surgery. A persistent increase in the prevalence of intra-abdominal infections caused by multidrug resistant pathogens has led researchers to investigate shorter-course antimicrobial therapy and other antibiotic administration strategies with encouraging initial results. Therapy with recombinant human activated protein C should now be considered for patients with severe abdominal sepsis associated with a high risk of death.
Because randomized controlled trials of intra-abdominal infections involve critically ill patients infrequently, only limited evidence-based recommendations regarding the management of these patients may be drawn. Therapy should focus above all else on timely obtainment of adequate source control, in conjunction with judicious use of antimicrobial therapy dictated by individual patient risk factors for infection with multidrug resistant pathogens.
本文旨在概述危重症期间腹腔内感染治疗三大基石的进展：源头控制、抗菌治疗以及减轻免疫和凝血反应紊乱。
尽管充分的源头控制仍是腹腔内感染机械管理的目标，但与按需再次剖腹手术相比，计划性再次剖腹手术和开放腹腔管理似乎均未带来生存获益。恢复功能性胃肠道的新方法已出现，可替代侵入性更强的手术。由多重耐药病原体引起的腹腔内感染患病率持续上升，促使研究人员探索疗程更短的抗菌治疗及其他抗生素给药策略，初步结果令人鼓舞。对于伴有高死亡风险的严重腹部脓毒症患者，现在应考虑使用重组人活化蛋白C进行治疗。
由于腹腔内感染的随机对照试验很少涉及危重症患者，因此关于这些患者管理的循证推荐有限。治疗应首先着重于及时实现充分的源头控制，并结合根据个体患者感染多重耐药病原体的风险因素明智地使用抗菌治疗。
