Ballus Josep, Lopez-Delgado Juan C, Sabater-Riera Joan, Perez-Fernandez Xose L, Betbese Antoni J, Roncal Joan A
1 Intensive Care Department, Hospital Universitari de Bellvitge , IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge). L'Hospitalet de Llobregat, Barcelona, Spain .
2 Intensive Care Department, Hospital de la Santa Creu i Sant Pau , Barcelona, Spain .
Surg Infect (Larchmt). 2017 Jul;18(5):588-595. doi: 10.1089/sur.2016.018. Epub 2017 Mar 29.
Critically ill surgical patients remain at a high risk of adverse outcomes as a result of secondary peritonitis (SP). The risk is even higher if tertiary peritonitis (TP) develops. Factors related to the development of TP, however, are scarce in the literature. The main aim of our study was to identify factors associated with the development of TP in patients with SP in the intensive care unit (ICU), and also to report differences in microbiologic patterns and antibiotic therapy in patients with the two conditions.
A prospective, observational study was conducted at our institution from 2010 to 2014. Baseline characteristics on admission, outcomes, microbiologic results, and antibiotic therapy were recorded for analysis.
We included 343 patients with SP, of whom TP developed in 185 (53.9%). Almost two-thirds (64.4%) were male; mean age was 63.7 ± 14.3 years, and mean APACHE was 19.4 ± 7.8. In-hospital death was 42.6% (146). Multivariable analysis showed that longer ICU stay (odds ratio [OR]: 1.019; 95% confidence interval [CI]: 1.004-1.034; p = 0.010), urgent operation on hospital admission (OR: 3.247; 95% CI: 1.392-7.575; p = 0.006), total parenteral nutrition (TPN) (OR: 3.079; 95% CI: 1.535-6.177; p = 0.002) and stomach-duodenum as primary infection site (OR: 4.818; 95% CI: 1.429-16.247; p = 0.011) were factors associated with the development of TP, whereas patients with localized peritonitis were less prone to have TP develop (OR: 0.308; 95% CI: 0.152-0.624; p = 0.001). Higher incidences of Candida spp. (OR: 1.275; 95% CI: 1.096-1.789; p = 0.016), Enterococcus faecium (OR: 1.085; 95% CI: 1.018-1.400; p = 0.002), and Enterococcus spp. (OR: 1.370; 95% CI: 1.139-1.989; p = 0.047) were found in TP, and higher rates of cephalosporin use in SP (OR: 3.51; 95% CI: 1.139-10.817; p = 0.035).
Complicated peritonitis remains a cause of a high numbers of deaths in the ICU. The need for TPN, urgent operation on hospital admission, and particularly surgical procedures in the proximal gastrointestinal tract were factors associated with development of TP and may potentially help to identify patients with SP at risk for development of TP. Physicians should be aware concerning multi-drug-resistant germs when treating these patients.
重症外科患者因继发性腹膜炎（SP）而面临不良结局的高风险。如果发展为三级腹膜炎（TP），风险会更高。然而，文献中关于TP发生相关因素的报道较少。本研究的主要目的是确定重症监护病房（ICU）中SP患者发生TP的相关因素，并报告这两种情况患者的微生物模式和抗生素治疗差异。
2010年至2014年在我院进行了一项前瞻性观察研究。记录入院时的基线特征、结局、微生物学结果和抗生素治疗情况以供分析。
我们纳入了343例SP患者，其中185例（53.9%）发展为TP。近三分之二（64.4%）为男性；平均年龄为63.7±14.3岁，平均急性生理与慢性健康状况评分系统（APACHE）评分为19.4±7.8。院内死亡率为42.6%（146例）。多变量分析显示，ICU住院时间延长（比值比[OR]：1.019；95%置信区间[CI]：1.004 - 1.034；p = 0.010）、入院时紧急手术（OR：3.247；95% CI：1.392 - 7.575；p = 0.006）、全胃肠外营养（TPN）（OR：3.079；95% CI：1.535 - 6.177；p = 0.002）以及胃十二指肠作为原发性感染部位（OR：4.818；95% CI：1.429 - 16.247；p = 0.011）是与TP发生相关的因素，而局限性腹膜炎患者发生TP的可能性较小（OR：0.308；95% CI：0.152 - 0.624；p = 0.001）。TP患者中念珠菌属（OR：1.275；95% CI：1.096 - 1.789；p = 0.016）、粪肠球菌（OR：1.085；95% CI：1.018 - 1.400；p = 0.002）和肠球菌属（OR：1.370；95% CI：1.139 - 1.989；p = 0.047）的发生率较高，SP患者头孢菌素的使用率较高（OR：3.51；95% CI：1.139 - 10.817；p = 0.035）。
复杂性腹膜炎仍是ICU中导致大量死亡的原因。TPN的需求、入院时紧急手术，尤其是上消化道的外科手术是与TP发生相关的因素，可能有助于识别有发生TP风险的SP患者。治疗这些患者时，医生应注意多重耐药菌问题。
