A Comprehensive review of abdominal infections

IAI causes volume depletion by several mechanisms. Nausea, anorexia and ileus lead to a decrease in oral intake, while vomiting and diarrhea increase sensible losses. In addition, ileus with third space losses into the bowel wall and ascites, as well as fever both increase insensible losses. Elevated body temperature leads to both an increase in dermal loss via sweating, and an increase in respiratory loss by causing tachypnea. Dermal loss in a febrile patient can account for approximately 600 ml of volume loss per day, while tachypnea causes approximately 100 ml of volume loss per day[20, 21].

In uncomplicated IAI, replacing volume is essential; in severe sepsis or septic shock, it becomes critical. Patients suspected of having severe sepsis or septic shock should be admitted to an ICU for careful monitoring of vital signs and volume status. With regard to the initial volume resuscitation, we recommend following the Surviving Sepsis Campaign recommendations. As soon as hypotension is recognized, or, ideally if it is anticipated, attention should be paid to early goal directed volume resuscitation. Isotonic fluid, or in the cases of severe anemia or coagulopathy, blood products, should be administered with the intent to achieve a mean arterial pressure (MAP) > 65 mmHg and a central venous pressure (CVP) of 12-15 mmHg within the first 6 hours[22]. If a MAP > 65 mmHg cannot be obtained by volume resuscitation alone then vasopressors should be used, with a preference for norepinepherine or dopamine[22]. In cases where low cardiac output or elevated filling pressures indicate severe myocardial dysfunction, use of inotropic agents such as dobutamine may be efficacious in obtaining adequate MAP[22]. Care should also be taken to monitor clinical indicators of end organ perfusion, such as hourly urine output and mental status, to ensure adequate oxygen delivery.

The goal of resuscitation is correction of cellular oxygen debt. Various endpoints for resuscitation have been suggested, including: mixed venous oxygen (SVO₂), lactate and base deficit. While a normal or high SVO₂ does not ensure adequate tissue oxygenation, a low SVO₂ indicates a need to increase tissue oxygenation. Resuscitation to maintain an SVO₂ > 65% has been shown to improve outcomes[23, 24]. Lactate, a product of anaerobic metabolism, has also been used as an indirect measure of oxygen debt. More recently sepsis has been recognized as a hypermetabolic state that uses glycolysis in the absence of hypoxia, making it less reliable as a marker of oxygen debt. Still, its early normalization may predict improved outcomes[25‐27]. Base deficit is yet another indicator of oxygen debt. It describes the amount of base that would be required to bring the blood to a normal pH under normal physiologic conditions. The degree of base deficit has been shown to correlate with resuscitation requirements and mortality[28, 29]. While none of these measures are perfect, they can be helpful in guiding resuscitation when used in combination with the other clinical endpoints discussed above.

The goal of drainage is to evacuate purulent, contaminated fluid, or to control drainage of ongoing enteric contamination. This is accomplished by either percutaneous or open surgical intervention. Percutaneous drainage can be performed with or without image guidance, and is most commonly performed using ultrasound or CT. In many circumstances it is as efficacious as surgical drainage, and is often used as the initial treatment of choice because it is less invasive and more affordable[30, 31]. Percutaneous drainage is also useful in patients who are poor surgical candidates, and might not survive definitive surgical treatment. However, percutaneous drainage is unlikely to result in adequate source control in cases of frank bowel perforation with ongoing contamination, or if there is a significant amount of necrotic tissue present. In these cases, surgery is the treatment of choice.

Open surgical drainage should be used in the case of generalized peritonitis, ongoing gross contamination from an uncontrolled enteric source, if bowel necrosis or ischemia is suspected, and in cases of failure of percutaneous drainage. Unstable patients, or those with complicated or difficult anatomy such as post-operative patients or those with advanced malignancy pose a particular challenge.

In these situations, damage control techniques can be employed with temporary abdominal closure. Damage control procedures are typically used for patients who are unstable and unable to tolerate definitive surgical treatment, have intra-abdominal hypertension (IAH), or have loss of abdominal domain that prevents fascial closure. The first stage in damage control surgery is evacuation of infected material and control of gross contamination. This is followed by temporary abdominal closure with a conventional dressing, negative pressure dressing, or skin closure. This first operative stage is followed by ongoing resuscitation, once normal physiology is restored resuscitation can then be followed by planned re-laparotomy for definitive source control and reconstruction. In cases of physiologic worsening after first laparotomy, or in cases of concern for IAH, or intestinal ischemia, on demand repeat laparotomy can be performed. Once all surgical issues have been addressed, physiology has been restored and there are no longer concerns for ongoing ischemia, necrosis, or IAH the abdomen can be definitively closed.

Intra-abdominal lavage is a subject of ongoing controversy. Proponents of peritoneal lavage reason that contamination is both removed and diluted by lavage volumes greater than 10 L, additionally, by adding antibiotics bacterial pathogens can be specifically targeted. One group has suggested that lavage with volumes of approximately 20 L reduces infectious complications in blunt traumatic small bowel perforation[32]. However, its application with or without antibiotics in abdominal sepsis is largely unsubstantiated; at this time there is minimal evidence in the literature to support its use[33, 34].

Debridement is essential for removal of foreign bodies, fecal matter, hematoma, and infected or necrotic tissue. The necessity to remove fibrin deposits is controversial. One early study showed improved postoperative courses with fewer continued infections; however, more recent studies have shown no benefit to this strategy[35, 36].

Definitive management involves restoration of anatomy and function. While staged procedures were once the standard, single stage procedures with primary anastomoses have become accepted as both safe and cost effective in the stable patient[37]. Still, establishing bowel continuity may need to be delayed in patients who are unable to tolerate a lengthy procedure or have inadequate capacity for tissue healing[38].

Acute appendicitis is the most common intra-abdominal surgical emergency[19]. Lifetime risk is approximately 7-9%[39]. Currently, imaging is recommended for all patients suspected of having appendicitis except men under 40 years of age[40]. Generally, CT scan is the accepted imaging modality, however, ultrasound may have a role in women at risk for other pelvic pathologies, in pregnancy and in children[41]. The sensitivity and specificity of CT scan in the diagnosis of acute appendicitis are 87-100% and 91-98%, respectively[42, 43]. Ultrasound is very user dependent, and results can be affected by patient body habitus, however overall sensitivity is 76-96% and specificity is 91-100%[44]. Ultrasound, with its decreased cost, lack of ionizing radiation and ability to assess ovarian pathology, has been the preferred initial imaging modality in children[45‐47]. However, CT should be used in children when the initial ultrasound is negative or non-diagnostic and there is a high clinical suspicion for appendicitis[45, 48]. Ultrasound is also the initial imaging procedure of choice in pregnant women, however, the appendix is visualized only 13-50% of the time. Magnetic resonance imaging (MRI) is an emerging imaging modality for cases of appendicitis in pregnancy with non-visualization of the appendix on ultrasound. Its sensitivity and specificity are 100% and 93.6%, respectively[49].

Though acute appendicitis is a very common entity, its management still contains areas of controversy including the role of laparoscopy, and the emerging role of medical management. These decisions can be complicated by the presence of an abscess or phlegmon.

Surgical management of acute appendicitis has been the gold standard of treatment for decades. However, many groups have proposed that in select patients, acute uncomplicated appendicitis can be treated with antibiotics alone. Initial success rates for conservative management of acute appendicitis range from 88-95%; however, recurrence is common, occurring in up to 35% of cases[50].

Both laparoscopic and open appendectomy are safe and effective. In large reviews, laparoscopic appendectomy has been associated with fewer surgical site infections, less pain, shorter hospital stays, and more rapid return to normal activity[51]. Common disadvantages found include increased cost and longer operative times[52, 53]. Additionally, laparoscopy has been associated with increased risk of intra-abdominal abscess formation, especially in the presence of perforation or gangrene. In these cases, open surgery may be preferred[54]. Ultimately, the differences in outcomes between laparoscopic and open appendectomy are largely equivocal and the decision should be based on available technology and surgeon expertise, with increased consideration for laparoscopy in young female or obese patients[51, 55, 56].

Management of patients presenting with abscess or phlegmon is conservative, with antibiotics and drainage initially. Traditionally this has been followed by interval appendectomy. However, recently the need for interval appendectomy has been questioned. Controversy primarily surrounds the issues of recurrence and potential for malignancy. In a large review the recurrence rate was 7.4% and the risk of malignancy 1.2%[57]. This is in accord with similar studies that conclude that in asymptomatic patients, interval appendectomy has no advantages over a thorough work up for inflammatory appendiceal masses[58, 59].

After bleeding, perforation is the second most common complication requiring emergent operative intervention in peptic ulcer disease[60, 61]. Helicobacter pylori infection is the most common cause of gastric and duodenal ulcers. Since the development of treatments for H. pylori, its prevalence in the United States has decreased. However, prevalence of gastric and duodenal ulcers has remained the same[62].

Previously, ulcer perforation was treated by excision and vagotomy. However, with antimicrobial eradication and anti-secretory pharmaceuticals, H. pylori positive ulcer recurrence has been significantly reduced[63]. As a result, the current standard of care is simple ulcer excision and primary repair of the bowel defect, or omental patch and subsequent H. pylori eradication, with little or no role for anti-secretory ulcer surgery[61, 64].

Both open and laparoscopic approaches are reasonable options for treatment of perforated peptic ulcers. Laparoscopic surgery is associated with significantly less pain, but downfalls include longer operative times, and potentially inadequate repair of large perforations. Comparisons of sutured versus non-sutured repair with fibrin glue plug reveal that both are safe[65].

Conservative management has also been proposed as a safe option for management of contained or sealed gastroduodenal perforations. One randomized study showed similar morbidity and mortality for operative and conservative approaches; however, conservative treatment was associated with longer hospital stays and increased failure in patients over 70 years old[66]. Similarly, another author suggests that patients less than 40 years old and not on NSAIDS are the most likely to be infected with H. pylori and therefore, the most likely to benefit from non-operative therapy[67]. Alternatively, one group suggests that non-operative therapy can be guided by documented self-sealing on gastroduodenogram[68].

Diverticular disease has increased since the turn of the 20th century[69]. The prevalence of diverticular disease among the general population is unknown, but at autopsy more than 50% of people over 80 years old are affected[70]. The lifetime prevalence of diverticulitis among patients with diverticulosis is 10-25%[69].

The standard treatment for uncomplicated diverticulitis is bowel rest and antibiotics. Most patients with uncomplicated diverticulitis respond to conservative management. Two studies found that patients who did not respond to antibiotics within 48 hours were more likely to require prolonged hospital stays for IV antibiotics and/or surgical intervention[71, 72].

Diverticulitis can be complicated by phlegmon, abscess, or free perforation and is generally classified according to modified Hinchey criteria[73]. Approximately 15-20% of cases are associated with abscesses[74]. In cases of uniloculated abscess, the initial treatment is usually percutaneous drainage; although, in small abscesses (< 4 cm), antibiotics have been used as a primary treatment with success rates comparable to drainage[75, 76]. When percutaneous drainage is performed it has success rates of up to 90%[77]. Of importance, the success of percutaneous drainage also seems to be dependent upon location. Ambrosetti and colleagues found that compared to mesocolic abscesses, pelvic abscesses were more aggressive, needed earlier drainage, and were more likely to require surgery[78].

Traditionally, patients who present with an abscess or phlegmon then undergo elective surgery to avoid the high risk of recurrence and further complications[71, 73]. Recently though, some have begun to question the need for operative therapy when initial management with percutaneous drainage and antibiotics is successful[79]. Two authors have found that perforation, which is the most common cause of mortality in complicated diverticulitis, is more likely to be the initial presentation of disease, rather than a manifestation of recurrence[79, 80]. They concluded that abscesses in complicated diverticulitis might then be adequately managed with antibiotics and drainage alone.

While conservative management may be appropriate in uniloculated abscesses, timely initial operative management is required for cases in which abscesses are large, multiloculated, or inaccessible, as well as in cases of free perforation, or diffuse peritonitis. Acute diverticulitis is complicated by free perforation in approximately 1.5% of episodes[81]. The standard procedure in cases of peritonitis is a Hartmann's procedure. However, the Hartmann's procedure is associated with significant morbidity and mortality, and while it can be reversed in 3-6 months, 30-70% of patients never undergo reversal[82‐86]. Recently, it has been suggested that primary resection and anastomosis should be preferred[83, 86, 87]. Finally, laparoscopic resections for complicated diverticulitis have also been shown to be safe; and, in spite of longer operative times, they are associated with fewer major complications, less pain, and shorter hospital stays[88].

Because resistant organisms have been linked to imprudent use of antibiotics, it is important to limit the duration of antimicrobial treatment[105]. Previously, studies have suggested limiting treatment duration for IAI by discontinuing antibiotics when fever and leukocytosis have resolved, and the patient is tolerating an oral diet[106]. More recently, it has been suggested that fixed duration treatment has similar efficacy[107]. The Surgical Infection Society (SIS) recommends that duration for complicated abdominal infections should be limited to 4-7 days, and may be discontinued sooner in the absence of clinical signs of infection[40]. In addition, once patients are able to tolerate oral intake, antibiotic therapy can be transitioned to oral dosing for the remainder of their treatment without increased risk of failure[108]. Suggested oral regimens for patients in whom resistance is not a concern are listed in Table 4. Of note, lack of resolution of clinical signs of infection after 7 days of antibiotics implies failed source control, tertiary peritonitis, or new infection. Further diagnostic work up including labs, cultures and imaging to look for new or continued sources of infection is essential, and should be accompanied by further surgical intervention if warranted[2].

Finally, we must consider patients with acute IAI, for which prompt source control is achieved. In cases where adequate source control is accomplished within 12-24 hours, less than 24 hours of antibiotic treatment is necessary (Table 5). Antibiotic choice in these instances should generally be guided by the aforementioned recommendations for low risk infections.