Critically ill patients with community-onset intraabdominal infections: Influence of healthcare exposure on resistance rates and mortality

Autoři: Emilio Maseda aff001;  Sofía Ramírez aff001;  Pedro Picatto aff003;  Eva Peláez-Peláez aff004;  Carlos García-Bernedo aff005;  Nazario Ojeda-Betancur aff006;  Gerardo Aguilar aff007;  Beatriz Forés aff008;  Jorge Solera-Marín aff009;  María Aliaño-Piña aff010;  Eduardo Tamayo aff011;  Fernando Ramasco aff012;  Raquel García-Álvarez aff013;  Ada González-Lisorge aff014;  María-José Giménez aff015;  Alejandro Suárez-de-la-Rica aff001
Působiště autorů: Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario La Paz, Madrid, Spain aff001;  Universidad Autónoma de Madrid, Madrid, Spain aff002;  Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario Central de Asturias, Oviedo, Spain aff003;  Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario Vall d’Hebron, Barcelona, Spain aff004;  Anesthesiology and Surgical Critical Care Dpt., Hospital del Mar, Barcelona, Spain aff005;  Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain aff006;  Anesthesiology and Surgical Critical Care Dpt., Hospital Clínico Universitario, Valencia, Spain aff007;  Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario Basurto, Bilbao, Spain aff008;  Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain aff009;  Anesthesiology and Surgical Critical Care Dpt., Hospital Virgen de la Salud, Toledo, Spain aff010;  Anesthesiology and Surgical Critical Care Dpt., Hospital Clínico Universitario, Valladolid, Spain aff011;  Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario de la Princesa, Madrid, Spain aff012;  Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario 12 de Octubre, Madrid, Spain aff013;  Anesthesiology and Surgical Critical Care Dpt., Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain aff014;  PRISM-AG, Madrid, Spain aff015;  Universidad Europea, Madrid, Spain aff016
Vyšlo v časopise: PLoS ONE 14(9)
Kategorie: Research Article
doi: 10.1371/journal.pone.0223092


The concept of healthcare-associated infections (as opposed to hospital-acquired infections) in intraabdominal infections (IAIs) is scarcely supported by data in the literature. The aim of the present study was to analyse community-onset IAIs (non-postoperative/non-nosocomial) in patients admitted to intensive care units (ICUs), to investigate differences in resistance patterns linked to healthcare exposure and mortality-associated factors. A one-year prospective observational study (17 Spanish ICUs) was performed distributing cases as healthcare-associated infections (HCAI), community-acquired infections (CAI) and immunocompromised patients (ICP). Bacteria producing extended-spectrum β-lactamases (ESBL) and/or carbapenemase (CPE), high-level aminoglycoside- and/or methicillin- and/or vancomycin- resistance were considered antimicrobial resistant (AMR). Mortality-associated factors were identified by regression multivariate analysis. Of 345 patients included (18.8% HCAI, 6.1% ICP, 75.1% CAI), 51.6% presented generalized peritonitis; 32.5% were >75 years (55.4% among HCAI). Overall, 11.0% cases presented AMR (7.0% ESBL- and/or CPE), being significantly higher in HCAI (35.4%) vs. CAI (5.8%) (p<0.001) vs. ICP (0%) (p = 0.003). Overall 30-day mortality was 14.5%: 23.1% for HCAI and 11.6% for CAI (p = 0.016). Mortality (R2 = 0.262, p = 0.021) was positively associated with age >75 years (OR = 6.67, 95%CI = 2.56–17.36,p<0.001), Candida isolation (OR = 3.05, 95%CI = 1.18–7.87,p = 0.022), and SAPS II (per-point, OR = 1.08, 95%CI = 1.05–1.11, p<0.001) and negatively with biliary infections (OR = 0.06, 95%CI = 0.01–0.48,p = 0.008). In this study, the antimicrobial susceptibility pattern of bacteria isolated from patients with healthcare contact was shifted to resistance, suggesting the need for consideration of the healthcare category (not including hospital-acquired infections) for severe IAIs. 30-day mortality was positively related with age >75 years, severity and Candida isolation but not with AMR.

Klíčová slova:

Antimicrobial resistance – Antimicrobials – Candida – Death rates – Intensive care units – Nosocomial infections – Peritonitis – Ascites


1. van Ruler O, Boermeester MA. Surgical treatment of secondary peritonitis: A continuing problem. Chirurg 2017;88(Suppl 1): 1–6. doi: 10.1007/s00104-015-0121-x 26746213

2. Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med 2013; 369: 2063.

3. Salamone G, Licari L, Falco N, Augello G, Tutino R, Campanella S, et al. Mannheim Peritonitis Index (MPI) and elderly population: prognostic evaluation in acute secondary peritonitis. G Chir 2016;37: 243–249. doi: 10.11138/gchir/2016.37.6.243 28350970

4. Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, et al. The Surgical Infection Society revised guidelines on the management of intra-abdominal infection. Surg Infect (Larchmt) 2017;18: 1–76.

5. Doklestić SK, Bajec DD, Djukić RV, Bumbaširević V, Detanac AD, Detanac SD, et al. Secondary peritonitis—evaluation of 204 cases and literature review. J Med Life 2014;7: 132–138. 25408716

6. Rausei S, Pappalardo V, Ruspi L, Colella A, Giudici S, Ardita V, et al. Early versus delayed source control in open abdomen management for severe intra-abdominal infections: A retrospective analysis on 111 cases. World J Surg 2018;42: 707–712. doi: 10.1007/s00268-017-4233-y 28936682

7. Hawser S, Hoban DJ, Badal RE, Bouchillon SK, Biedenbach D, Hackel M, et al. Epidemiology and antimicrobial susceptibility of gram-negative aerobic bacteria causing intra-abdominal infections during 2010–2011. J Chemother 2015;27: 67–73. doi: 10.1179/1973947814Y.0000000164 24548089

8. Lob SH, Badal RE, Bouchillon SK, Hawser SP, Hackel MA, Hoban DJ. Epidemiology and susceptibility of gram-negative appendicitis pathogens: SMART 2008–2010. Surg Infect (Larchmt) 2013;14: 203–208.

9. Sartelli M, Weber DG, Ruppé E, Bassetti M, Wright BJ, Ansaloni L, et al. Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA). World J Emerg Surg 2016;11: 33. doi: 10.1186/s13017-016-0089-y 27429642

10. Global Alliance for Infections in Surgery. How to classify intra-abdominal infections. Accessed 23 April 2018.

11. Kollef MH, Napolitano LM, Solomkin JS, Wunderink RG, Bae IG, Fowler VG, et al. Health care-associated infection (HAI): a critical appraisal of the emerging threat-proceedings of the HAI Summit. Clin Infect Dis 2008;47(Suppl 2): S55–S99.

12. Zalacain M, Biedenbach DJ, Badal RE, Young K, Motyl M, Sahm DF. Pathogen prevalence and antimicrobial susceptibility among Enterobacteriaceae causing hospital-associated intra-abdominal infections in adults in the United States (2012–2013). Clin Ther 2016;38: 1510–1521. doi: 10.1016/j.clinthera.2016.04.035 27234360

13. Hackel MA, Badal RE, Bouchillon SK, Biedenbach DJ, Hoban DJ. Resistance rates of intra-abdominal isolates from intensive care units and non-intensive care units in the United States: The Study for Monitoring Antimicrobial Resistance Trends 2010–2012. Surg Infect (Larchmt) 2015;16: 298–304.

14. Di Pasquale M, Ferrer M, Esperatti M, Crisafulli E, Giunta V, Li Bassi G, et al. Assessment of severity of ICU-acquired pneumonia and association with etiology. Crit Care Med 2014;42: 303–312. doi: 10.1097/CCM.0b013e3182a272a2 23989176

15. Vallés J, Martin-Loeches I, Torres A, Diaz E, Seijas I, López MJ, et al. Epidemiology, antibiotic therapy and clinical outcomes of healthcare-associated pneumonia in critically ill patients: a Spanish cohort study. Intensive Care Med 2014;40: 572–581. doi: 10.1007/s00134-014-3239-2 24638939

16. Bassetti M, Peghin M, Carnelutti A, Righi E, Merelli M, Ansaldi F, et al. Clinical characteristics and predictors of mortality in cirrhotic patients with candidemia and intra-abdominal candidiasis: a multicenter study. Intensive Care Med 2017;43: 509–518. doi: 10.1007/s00134-017-4717-0 28271321

17. Mahoney FI, Barthel DW. Functional evaluation: The Barthel index. Md State Med J 1965;14: 61–65.

18. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 1996;22: 707–710. doi: 10.1007/bf01709751 8844239

19. Le Gall JR, Lemeshow S, Saulnier F. A new simplified acute physiologic score (SAPS-II) based on a European/North-American multicenter study. JAMA 1993;270: 2957–2963. doi: 10.1001/jama.270.24.2957 8254858

20. Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010;50: 133–164. doi: 10.1086/649554 20034345

21. Maseda E, Mensa J, Valía JC, Gomez-Herreras JI, Ramasco F, Samso E, et al. Bugs, hosts and ICU environment: countering pan-resistance in nosocomial microbiota and treating bacterial infections in the critical care setting. Rev Esp Quimioter 2013;26: 312–331. 24399345

22. Labricciosa FM, Sartelli M, Abbo LM, Barbadoro P, Ansaloni L, Coccolini F, et al. Epidemiology and risk factors for isolation of multi-drug-resistant organisms in patients with complicated intra-abdominal infections. Surg Infect (Larchmt) 2018;19: 264–272.

23. Swenson BR, Metzger R, Hedrick TL, McElearney ST, Evans HL, Smith RL, et al. Choosing antibiotics for intra-abdominal infections: what do we mean by "high risk"?. Surg Infect (Larchmt) 2009;10: 29–39.

24. Hawser SP, Bouchillon SK, Hoban DJ, Badal RE. In vitro susceptibilities of aerobic and facultative anaerobic gram-negative bacilli from patients with intra-abdominal infections worldwide from 2005–2007: results from the SMART study. Int J Antimicrob Agents 2009;34: 585–588. doi: 10.1016/j.ijantimicag.2009.07.013 19748234

25. Hawser SP, Badal RE, Bouchillon SK, Hoban DJ, Hackel MA, Biedenbach DJ, et al. Susceptibility of gram-negative aerobic bacilli from intra-abdominal pathogens to antimicrobial agents collected in the United States during 2011. J Infect 2014;68: 71–76. doi: 10.1016/j.jinf.2013.09.001 24016768

26. Chong YP, Bae IG, Lee SR, Chung JW, Jun JB, Choo EJ, et al. Clinical and economic consequences of failure of initial antibiotic therapy for patients with community-onset complicated intra-abdominal infections. PLoS One 2015;10: e0119956. doi: 10.1371/journal.pone.0119956 25910171

27. Skalweit MJ. Profile of ceftolozane/tazobactam and its potential in the treatment of complicated intra-abdominal infections. Drug Des Devel Ther 2015;9: 2919–2925. doi: 10.2147/DDDT.S61436 26082619

28. de Ruiter J1, Weel J, Manusama E, Kingma WP, van der Voort PH. The epidemiology of intra-abdominal flora in critically ill patients with secondary and tertiary abdominal sepsis. Infection 2009;37: 522–527. doi: 10.1007/s15010-009-8249-6 19669089

29. Montravers P, Chalfine A, Gauzit R, Lepape A, Pierre Marmuse J, Vouillot C, et al. Clinical and therapeutic features of nonpostoperative nosocomial intra-abdominal infections. Ann Surg 2004;239: 409–416. doi: 10.1097/01.sla.0000114214.68169.e9 15075660

30. Lob SH, Kazmierczak KM, Badal RE, Hackel MA, Bouchillon SK, Biedenbach DJ, et al. Trends in susceptibility of Escherichia coli from intra-abdominal infections to ertapenem and comparators in the United States according to data from the SMART program, 2009 to 2013. Antimicrob Agents Chemother 2015;59: 3606–3610. doi: 10.1128/AAC.05186-14 25801558

31. Gauzit R, Péan Y, Barth X, Mistretta F, Lalaude O; Top Study Team. Epidemiology, management, and prognosis of secondary non-postoperative peritonitis: a French prospective observational multicenter study. Surg Infect (Larchmt) 2009;10:119–127.

32. Dupont H, Guilbart M, Ntouba A, Perquin M, Petiot S, Regimbeau JM, et al. Can yeast isolation be predicted in complicated secondary non-postoperative intra-abdominal infections?. Crit Care 2015;19: 60. doi: 10.1186/s13054-015-0790-3 25849844

33. Adrie C, Garrouste-Orgeas M, Ibn Essaied W, Schwebel C, Darmon M, Mourvillier B, et al. Attributable mortality of ICU-acquired bloodstream infections: Impact of the source, causative micro-organism, resistance profile and antimicrobial therapy. J Infect 2017;74: 131–141. doi: 10.1016/j.jinf.2016.11.001 27838521

34. Salamone G, Licari L, Falco N, Augello G, Tutino R, Campanella S, et al. Mannheim Peritonitis Index (MPI) and elderly population: prognostic evaluation in acute secondary peritonitis. G Chir 2016;37: 243–249. doi: 10.11138/gchir/2016.37.6.243 28350970

35. Montravers P, Dupont H, Gauzit R, Veber B, Auboyer C, Blin P, et al. Candida as a risk factor for mortality in peritonitis. Crit Care Med 2006;34: 646–652. doi: 10.1097/01.CCM.0000201889.39443.D2 16505648

36. Bassetti M, Marchetti M, Chakrabarti A, Colizza S, Garnacho-Montero J, Kett DH, et al. A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts. Intensive Care Med 2013;39: 2092–2106. doi: 10.1007/s00134-013-3109-3 24105327

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