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Management of Intra-Abdominal Infections: Recommendations by the WSES 2016 Consensus Conference Massimo Sartelli1*, Fausto Catena2, Fikri M

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Management of Intra-Abdominal Infections: Recommendations by the WSES 2016 Consensus Conference Massimo Sartelli1*, Fausto Catena2, Fikri M Sartelli et al. World Journal of Emergency Surgery (2017) 12:22 DOI 10.1186/s13017-017-0132-7 REVIEW Open Access Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference Massimo Sartelli1*, Fausto Catena2, Fikri M. Abu-Zidan3, Luca Ansaloni4, Walter L. Biffl5, Marja A. Boermeester6, Marco Ceresoli3, Osvaldo Chiara7, Federico Coccolini3, Jan J. De Waele8, Salomone Di Saverio9, Christian Eckmann10, Gustavo P. Fraga11, Maddalena Giannella12, Massimo Girardis13, Ewen A. Griffiths14, Jeffry Kashuk15, Andrew W. Kirkpatrick16, Vladimir Khokha17, Yoram Kluger18, Francesco M. Labricciosa19, Ari Leppaniemi20, Ronald V. Maier21, Addison K. May22, Mark Malangoni23, Ignacio Martin-Loeches24, John Mazuski25, Philippe Montravers26, Andrew Peitzman27, Bruno M. Pereira11, Tarcisio Reis28, Boris Sakakushev29, Gabriele Sganga30, Kjetil Soreide31, Michael Sugrue32, Jan Ulrych33, Jean-Louis Vincent34, Pierluigi Viale12 and Ernest E. Moore35 Abstract This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings. Keywords: Intra-abdominal infections, Sepsis, Peritonitis, Antibiotics Background Syndrome (WSACS). This document represents the ex- Intra-abdominal infections (IAIs) are an important cause ecutive summary of this consensus conference. of morbidity and mortality [1]. Early clinical diagnosis, adequate source control to stop ongoing contamination, Methodology appropriate antimicrobial therapy dictated by patient In constituting the expert panel, the WSES committee and infection risk factors, and prompt resuscitation in invited many of the world’s leading experts in the man- critically ill patients are the cornerstones in the manage- agement of IAIs. It was a multidisciplinary expert panel ment of IAIs. However, several critical controversies can including general and specialist surgeons, emergency be debated in the management of these patients. Appli- and acute care surgeons, infectious disease specialists, cation of management principles to the individual pa- and intensivists. The expert panel reviewed the scientific tient is crucial to optimize outcome. In order to clarify evidence and composed statements which addressed a these major controversies in the management of IAI, ’ set of predefined questions. many of the world s leading experts met in Dublin, The statements were formulated and graded according Ireland, on July 23, 2016, for a specialist multidisciplinary to the Grading of Recommendations Assessment, Develop- consensus conference under the auspices of the World ment and Evaluation (GRADE) hierarchy of evidence from Society of Emergency Surgery (WSES) and with the sup- Guyatt and colleagues [1], summarized in Table 1. port of the World Society of Abdominal Compartment During the WSES annual conference which was held in Dublin, the statements were debated and approved by * Correspondence: [email protected] 1Department of Surgery, Macerata Hospital, Macerata, Italy the committee jury panel. This document represents the Full list of author information is available at the end of the article executive summary of the final recommendations © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sartelli et al. World Journal of Emergency Surgery (2017) 12:22 Page 2 of 31 Table 1 Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence from Guyatt and colleagues [1] Grade of recommendation Clarity of risk/benefit Quality of supporting evidence Implications 1A Strong recommendation, Benefits clearly outweigh risk RCTs without important limitations Strong recommendation, high-quality evidence and burdens, or vice versa or overwhelming evidence from applies to most patients in observational studies most circumstances without reservation 1B Strong recommendation, Benefits clearly outweigh risk RCTs with important limitations Strong recommendation, moderate-quality evidence and burdens, or vice versa (inconsistent results, methodological applies to most patients in flaws, indirect analyses or imprecise most circumstances without conclusions) or exceptionally strong reservation evidence from observational studies 1C Strong recommendation, Benefits clearly outweigh risk Observational studies or case series Strong recommendation but low-quality or very low-quality and burdens, or vice versa subject to change when higher evidence quality evidence becomes available 2A Weak recommendation, Benefits closely balanced with RCTs without important limitations or Weak recommendation, best high-quality evidence risks and burden overwhelming evidence from action may differ depending observational studies on the patient, treatment circumstances, or social values 2B Weak recommendation, Benefits closely balanced with RCTs with important limitations Weak recommendation, best moderate-quality evidence risks and burden (inconsistent results, methodological action may differ depending flaws, indirect or imprecise) or on the patient, treatment exceptionally strong evidence from circumstances, or social values observational studies 2C Weak recommendation, Uncertainty in the estimates Observational studies or case series Very weak recommendation; Low-quality or very low-quality of benefits, risks, and burden; alternative treatments may be evidence benefits, risk, and burden may equally reasonable and merit be closely balanced consideration approved by the consensus conference. The document event of uncomplicated IAIs, the infection only involves was reviewed and approved by both the expert and a single organ and does not extend to the peritoneum. jury panels. When the focus of infection is controlled by surgical ex- cision, post-operative antibiotic therapy is not necessary What is the most appropriate classification for [3–5]. In the event of complicated IAIs (cIAIs), the infec- intra-abdominal infections? tious process proceeds beyond the organ into the periton- Statement 1 eum, causing either localized or diffuse peritonitis. The term “intra-abdominal infections” describes a Treatment of patients with cIAIs involves generally wide heterogeneity of clinical conditions. The anatom- both source control, antibiotic therapy, and potentially ical extent of infection, the presumed pathogens in- novel therapies targeted at modulating or ameliorating volved, risk factors for major resistance patterns, and the host inflammatory response. Antibiotics can prevent the patient's clinical condition should be assessed in- local and hematogenous spread and can reduce late dependently so as to classify patients (Recommenda- complications [6]. tion 1 C). This classification has been questioned by some au- A complete classification that includes the origin of thors because it often has incited confusion by mixing source of infection, the anatomical extent of infection, elements of anatomical barrier disruption and severity of the presumed pathogens involved and risk factors for disease expression [7]. major resistance patterns, and the patient’s clinical con- Peritonitis is an inflammation of the peritoneum. dition does not exist. Depending on the underlying pathology, it can be infec- A simple and universally accepted classification divides tious or sterile. Infectious peritonitis is classified into IAIs into complicated and uncomplicated [2]. In the primary peritonitis, secondary peritonitis, and tertiary Sartelli et al. World Journal of Emergency Surgery (2017) 12:22 Page 3 of 31 peritonitis [2]. Primary peritonitis is a diffuse bacterial Recently, the third International Consensus Definitions infection (usually caused by a single organism) without for Sepsis and Septic Shock (Sepsis-3) were published loss of integrity of the gastrointestinal tract, typically [19], replacing previous classifications [20, 21]. Sepsis is seen in cirrhotic patients with ascites or in patients with now defined as a life-threatening organ dysfunction a peritoneal dialysis catheter. It has a low incidence on caused by a dysregulated host response to infection. surgical wards and is usually managed without any surgi- Organ dysfunction can be represented by an increase in cal intervention. Secondary peritonitis, the most com- the Sequential [sepsis-related] Organ Failure Assessment mon form of peritonitis, is an acute peritoneal infection (SOFA) score of 2 points or more. Septic shock should resulting from loss of integrity of the gastrointestinal be defined as a subset of sepsis and should be clinically tract. Tertiary peritonitis is a recurrent infection of the identified by a vasopressor requirement to maintain a peritoneal cavity that occurs >48 h after apparently
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