Operative and nonoperative therapy of intraabdominal infections.

The basic principles for treating intraabdominal infections are fourfold: (1) to obliterate the infectious source; (2) to purge bacteria and toxins; (3) to maintain organ system function and (4) to tame the inflammatory process. Operative and nonoperative treatment options are available. Operative therapy includes different strategies: (1) the standard operation; (2) advanced procedures to decompress the abdominal compartment syndrome and (3) percutaneous drainage of abscesses. Nonoperative management includes: (1) antibiotic therapy; (2) hemodynamic and pulmonary support; (3) nutrition and metabolic support; (4) detoxification support (including support of renal and hepatic function) and (5) inflammation modulating therapy. Standard operative management addresses the first two principles and has been shown to reduce mortality by more than 50%. A recent extensive series of studies reports mortality rates around 20%. Patients with an abdominal compartment syndrome (intraabdominal pressure over 25 torr) and patients with advanced disease and compounding risk factors best documented by high APACHE-II scores are candidates for more advanced operations. The mortality rate following abdominostomy (leaving the abdomen open) in 869 patients participating in 37 studies was 42%, when the abdomen was simply left open for decompression (open abdominostomy). When a mesh was used to cover the abdominal wound (mesh abdominostomy) 39% of 439 patients enrolled in 12 studies died. Patients who underwent staged abdominal repair (STAR abdominostomy) faired better. Of 385 patients in 11 studies 28% died. Data from antibiotic studies as well as from immunomodulating therapy are nonconclusive at this point with respect to reducing mortality in intraabdominal infection.