Benefits of WSES guidelines application for the management of intra-abdominal infections
De Simone et al. World Journal of Emergency Surgery
Benefits of WSES guidelines application for the management of intra-abdominal infections
Belinda De Simone 0
Federico Coccolini 2
Fausto Catena 0
Massimo Sartelli 1
Salomone Di Saverio 5
Rodolfo Catena 4
Antonio Tarasconi 3
Luca Ansaloni 2
0 Department of Emergency and Trauma Surgery, University Hospital of Parma , Via Gramsci 11, 43100 Parma , Italy
1 Department of Surgery, Macerata Hospital , Macerata , Italy
2 Department of General and Emergency Surgery, Papa Giovanni XIII Hospital , Bergamo , Italy
3 Ospedali Civili di Brescia , Brescia , Italy
4 Oxford University , Oxford , Great Britain
5 Department of Surgery, Maggiore Hospital of Bologna , Bologna , Italy
Introduction: The use of antibiotics is very high in the departments of Emergency and Trauma Surgery above all in the treatment of the intra-abdominal infections, to decrease morbidity and mortality rates; often the antimicrobial drugs are prescribed without a rationale and they are second-line antibiotics; this clinical practice increases costs without decreasing mortality. Aim of our study is to report the results in the application to the clinical practice of the World Society Emergency Surgeons (WSES) guidelines for the management of intra-abdominal infections, at the department of Emergency and Trauma Surgery of the University Hospital of Parma (Italy) in 2012. Methods: A retrospective observational analysis was carried out about patients admitted in the department of Emergency and Trauma Surgery of Parma (Italy), between January 2011 and December 2012. The data are expressed as percentages (%) and means ( SD). The results of the compared groups were analyzed using the Pearson's Chi-Square and Fisher's tests. For means involving continuous numerical data, the independent sample T test and the Mann-Whitney U-test were used for normally and abnormally distributed data, respectively (the data had been previously tested for normality using the Kolmogorov-Smirnov test). A p-value < 0.05 was considered statistically significant. Results: Between January 2011 and December 2012, 2121 (968 in 2011 and 1153 in 2012) patients were admitted in the department of Emergency and Trauma Surgery (Italy) of Parma University Hospital with a diagnosis of acute IAI. Morbidity in 2012 was 10,2% compared to 22.7% in 2011 and mortality in 2012 was 1,1% compared to 3,2% in 2011 (p < 0,05). Costs for antibiotics in 2012 was 51392 euro, with a reduction of 31% compared to 2011. Conclusions: This study demonstrates that an inexpensive and easily application of guidelines based on medicine evidence in the use of antibiotics can lead to a significative reduction of hospital costs with outcomes improvement.
Intra-abdominal infections; Antibiotics; WSES guidelines; Cost-effectiveness
Antibiotics are the essential drugs that we have to fight
and prevent bacterial infectious diseases. Improper and
excessive use of antibiotics is the major worldwide
problem because it has an important economic impact
on increasing healthcare costs, caused by the selection
of multi-drug resistant bacteria, resulting in a longer
hospital stay and an higher mortality . For the World
Health Organization (WHO), the rational use of drugs
requires that patients receive medications appropriate to
their clinical needs, in doses that meet their own
individual requirements, for an adequate period of time and at
the lowest cost, to them and their community ;
because each antibiotic has different unit dose of daily
administration, a specific standardized method to
evaluate the in-hospital antibiotic use was suggested and
periodically update by WHO, the ATC/DDD index
(Anatomical Therapeutic Chemical/Defined Daily Dose):
it is considered the universal parameter to calculate the
antibiotic use intensity . Furthermore, the use of
antibiotic prophylaxis, according to standardized
protocols, has been shown to prevent post-surgical wound
infections, which are the primary cause of morbidity and
mortality in patients undergoing surgery.
The use of antibiotics is very high in the departments
of Emergency and Trauma Surgery, above all in the
treatment of the intra-abdominal infections (IAIs) to
decrease morbidity and mortality rates. Often the
antimicrobial drugs are prescribed without a rationale
and they are second-line antibiotics; this clinical practice
increases costs without decreasing mortality . Sartelli
et al., during the 1st Congress of the World Society
of Emergency Surgeons (WSES), discussed in a
multidisciplinary approach these problems, approving
evidence based recommendations for the management of
IAIs . According to the WSES guidelines, the initial
antibiotic therapy for IAIs is always empiric because the
patient is often critically ill and microbiological data
(culture and susceptibility results) usually take at least
48 hours to become fully available . IAIs are classified
as uncomplicated and complicated. The uncomplicated
infections involve a single organ and do not spread to
the peritoneum (antimicrobial therapy is indicated as
first line approach); the complicated IAIs proceed
beyond a single organ, causing localized or diffuse
peritonitis and need for surgical and antimicrobial
IAIs are divided in 3 sub-groups: 1. community
acquired extrabiliary infections: gastroduodenal
perforations, small bowel perforations, acute appendicitis,
acute diverticulitis, large bowel perforations; 2.
community acquired biliary infections:acute cholecystitis,
cholangitis; 3. hospital acquired infections:
postoperative and non-postoperative peritonitis. Once the
diagnosis of intra-abdominal infection is suspected, it is
necessary to begin, as soon as possible, the empiric
antimicrobial therapy, even if routine use of
antimicrobial therapy is not appropriate for all patients with
intra-abdominal infections. Source control should be
obtained as early as possible after the diagnosis of
postoperative intra-abdominal peritonitis has been
The principles of empiric antibiotic treatment should
be defined according to the most frequently isolated
germs, always taking into consideration the local trend
of antibiotic resistance. The choice of the antimicrobial
regimen depends on the source of intra-abdominal
infection, the risk factors for specific microorganisms, the
resistance patterns and the clinical patients condition.
In uncomplicated IAIs, when the focus of infection is
treated effectively by surgical excision of the involved
tissue, the administration of antibiotics is unnecessary
beyond prophylaxis. In complicated IAIs, antimicrobial
therapy is mandatory. Hospital acquired infections are
commonly caused by larger and more resistant flora,
and for these infections, complex multi-drug regimens
are always recommended .
We report the results in the application to the clinical
practice of the WSES guidelines for the management of
intra-abdominal infections at the Department of
Emergency and Trauma Surgery of Parma University Hospital
(Italy) in 2012.
Materials and methods
A retrospective observational analysis was carried out
about patients with IAIs admitted to the Department
of Emergency and Trauma Surgery of Parma University
Hospital, between January 2011 and December 2012
The following parameters were collected: patients
demographics, diagnosis, surgical procedures performed,
antibiotic treatment, length of hospital stay (day) and
outcomes. In 2011 and 2012, the same antibiotic drugs
were available in our hospital, at the same price.
In 2011, no guidelines were used, whereas in 2012
WSES IAIs guidelines were utilized. (Figure 1)
Community acquired extra-biliary IAIs (gastro-duodenal
perforations, small bowel perforations, acute
appendicitis, acute diverticulitis, large bowel perforations)
were treated with Ampicillin/Sulbactam or Ciprofloxacin
(in patients with allergic reaction to Penicillin) +/
Community acquired biliary IAIs (cholecystitis, cholangitis)
were treated with Ampicillin/Sulbactam or Ciprofloxacin,
if allergic reaction to Penicillin, +/ Metronidazole, as
first line therapy, if an ESBL or MDR pathogens were
Hospital acquired IAIs needed for a large spectrum
therapy (high risk of ESBL or MDR pathogens involved) with
Piperacillin/Tazobactam or Meropenem +/Fluconazole +/
Tigecycline. Critically ill patients were often
hospitalized in ICU.
All antibiotic treatments started with an i.v.
administration followed by oral switch when appropriate (normal
infection signs, normal infection laboratory parameters
and resumption of oral feeding).
The data are expressed as percentages (%) and means
( SD). The results of the compared groups were
analyzed using the Pearsons Chi-Square and Fishers Exact
tests, as appropriate, for proportions involving discrete
data. The Fishers Exact test was used when the data
were unequally distributed among the cells of the table,
when the expected frequency of any cell was less than 5,
or when the total number (N) was less than 50.
For means involving continuous numerical data,
the independent sample T test and the MannWhitney
U-test were used for normally and abnormally distributed
data, respectively (the data had been previously tested
Figure 1 WSES IAIs guidelines.
for normality using the Kolmogorov-Smirnov test). A
p-value < 0.05 was considered statistically significant.
Between January 2011 and December 2012, 2121 (968 in
2011 and 1153 in 2012) patients were admitted in the
Department of Emergency and Trauma Surgery of
Parma University Hospital with a diagnosis of acute IAI.
The mean age was 58,8 years (SD 9,1) in 2011 and 59,1
in 2012 (SD 8.9); (p = n.s.). Male/ female ratio was 1,04
in 2012 and 1,02 in 2011 (p = n.s.). Complicated IAIs
were 41,1% in 2012 and 38,7% in 2011. (p = n.s.).
Empirical treatment was performed in 91,8% of
patients in 2012 and in 95,3% of patients in 2011 (p = n.s.).
Figure 2 IAI patients divided according to admission diagnosis in 2011 and in 2012.
Ampicillin/Sulbactam plus Metronidazole, and Piperacillin/
Tazobactam. The oral switch was performed in 540/ 968
(55,7%) patients in 2011 and in 691/1153 (59,9%) in 2012.
(p = n.s.).
The mean length of intravenous therapy was 4.9 days
(range 211) (DS 3,67) and the mean lenght of oral therapy
was 3.23 days (range 133) (DS 3,18) in 2012, whereas the
mean length of intravenous therapy was 5.4 days (range
332) (DS 4,22) and the mean lenght of oral therapy was
4,59 days (range 184) (DS 2,25); (p = n.s.) in 2011. Mean
lenght of hospital stay was 7.5 days (range 431) (DS 6,08)
in 2012 and 8,9 days (range 491) (DS 5,36) in 2011 (p = n.s.).
In-hospital mortality rate was 1.10% in 2012 vs 3.2% in
2011 (p < 0.05.) and morbidity was 10,2% in 2012 vs
22,7% in 2011 (p < 0.05). Costs for antibiotics in 2012
was 51392 euro compared to 75327 euro in 2011 (31,7%
reduction). More common bacteria isolates were
comparable between 2011 and 2012.
Figure 3 Surgical procedures performed as source control on IAI patients in 2011 and in 2012.
Figure 4 The administrated antibiotic treatments in 2011 and in 2012.
Its worldwide accepted that a remarkable amount of
antibiotics used in hospitalized patients is excessive or
inappropriate; this irrational use of antibiotics leads to the
emergence of drug resistant bacteria, associated with an
higher rates of death, illness and prolonged hospital stay,
with a considerable increasing of the healthcare costs.
Besides the research involved with the development of
new antibiotics has no progressed in parallel with the
increasing rates of resistance, leaving clinicians with fewer
options, often more expensive, for the treatment of some
In the recent literature, several studies argue on the
necessity of the diffusion of valid guidelines, based on
clinical evidence and on the bacterial resistance
epidemiology, to rationalize the use of antibiotics [2-6]. Many
authors highlight on the importance of the application
of validated guidelines in clinical practice and of the
surgical prophylaxis protocols, associated with adequate
education programs for physicians and surgeons on the
diligent prescription and administration of antibiotics,
in reducing healthcare costs with considerable benefits
in terms of cost-effectiveness [7-11].
In the present study, the application of WSES
guidelines for the management of intra-abdominal infections
was highly effective in reducing the number of
unnecessary second-line antibiotics prescriptions and costs; it
led to a 31% reduction of costs for antimicrobial drugs,
keeping low morbidity and low mortality rates. The source
control associated with an adequate antimicrobial therapy
are efficacy to decrease morbidity and mortality rates.
This study demonstrates that an inexpensive and easily
application of guidelines based on medicine evidence in
the use of antibiotics can lead to a significant reduction
of hospital costs. There is an urgent need to develop
education programs, to spread valid guidelines in the use
of antimicrobial agents, to limit the emergence of bacterial
resistance, responsible of the increasing in the incidence
of difficult infectious diseases and deaths, and to reduce
costs resulting from this global problem [10-12].
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