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Surgical Site Infections and Intra-Abdominal Infections

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Early detection of surgical site bacterial infections 

Despite precautions and protocols in place to prevent infection, millions of healthcare-associated infections (HAI) occur each year.1 Surgical site infections (SSI) are the most surveyed and frequent type of HAI in low- and middle-income countries and the second most frequent type of HAI in Europe and the United States.2 

They may lead to:

  • longer postoperative hospital stays
  • additional surgical procedures
  • admission to intensive care units
  • higher mortality
Surgical site infections increase the mortality risk up to 11-fold and lead to longer hospital stays and increased costs.3

Procalcitonin (PCT) in postoperative patients:  Non-infected cases 

PCT levels may be moderately raised following surgery. For the correct interpretation of the rise in level, it is important to be mindful of the following:


PCT induction after surgery:

  • Is common in surgical procedures and depends on the type and extent of operation
  • Is transient and moderate
  • Occurs due to physiological trauma of surgery
  • The more severe the surgical tissue trauma, the higher the elevation of PCT
  • Is primarily not because of infection
  • Indicates a pro-inflammatory status

PCT in postoperative patients: Infected cases 

Serial PCT measurements are important to differentiate SSIs from normal post-surgical inflammation.

In cases of postoperative infections, a clear PCT elevation is seen.

Infected Cases

    Meisner et al., Crit Care. 2006 Feb;10(1):R1. doi: 10.1186/cc3910.

How to identify surgical site infections before the emergence of apparent clinical signs

Serial measurement of PCT levels, rather than relying on a single value, can help differentiate surgical site infections (SSIs) or progression to infection or sepsis from normal post-surgical inflammation.

The high specificity of the biomarker PCT allows for early identification of bacterial infections, helping clinicians make earlier diagnosis in surgical patients. In addition, the rapid increase of PCT in response to infection—in many cases before an infected patient presents symptoms—can further reduce time to diagnosis while minimizing infection severity.5

PCT

    Amour J, Birenbaum A, Langeron O, Le Manach Y, Bertrand M, Coriat P, et al. Influence of renal dysfunction on the accuracy of procalcitonin 
for the diagnosis of postoperative infection after vascular surgery. Crit Care Med. 2008 Apr 1;36(4):1147-54.

Serial measurement of PCT levels is important for distinguishing between infectious and non-infectious causes of PCT elevation, enabling the early detection of infectious complications.
Identify surgical site infections early to safely reduce antibiotic exposure

PCT reduces antibiotic therapy, costs and length of stay in ICU

In one study, B·R·A·H·M·S PCT™ aided antibiotic therapy in 102 patients after open-heart surgery reduced antibiotic prescription by 60% and lowered the mean antibiotic cost per hospital-day.7 And in another study, PCT-aided antibiotic therapy significantly reduced the number of days of antibiotic use as well as the duration of ICU stay in patients with confirmed or high-grade suspected infections.8

PCT is superior to C-reactive protein in identifying bacterial surgical site infections

When assessing a patient for surgical site infections, PCT identifies postoperative infections more reliably than other biomarkers such as C-reactive protein (CRP). This is because a rise of PCT levels has a higher specificity for bacterial infection, and is less impacted by non-infectious surgery- or trauma-associated inflammation.9   

PCT, CRP, and IL-6 in patients undergoing aortal surgey (n=25)

CRP-IL-6

Antibiotic Guidance and Decision Making in Intra-Abdominal Infections

Intra-abdominal infections (IAIs) are a major contributor to morbidity and mortality in hospitals worldwide.10 PCT serves as a valuable biomarker to guide the duration of antibiotic therapy in patients showing signs of persistent infection.10 The World Society of Emergency Surgery Biomarkers in Acute Care Surgery & Trauma Initiative (WSES-BACS&TI) provides comprehensive access to literature on the application of biomarkers within acute care surgery and trauma contexts.

Initiative WSES BACS TI

Patients who continue to show signs of infection after undergoing a source control procedure and completing an appropriate fixed-duration antibiotic regimen should be evaluated for a persistent source of infection, such as failed source control or untreated resistant pathogens. This evaluation helps determine whether re-operation is necessary rather than simply prolonging or modifying the antibiotic treatment regimen. In such cases, PCT levels may aid in tailoring antibiotic use to individual needs.10

Acute Pancreatitis

Acute pancreatitis is an inflammatory disorder of the pancreas with an incidence of 150 to 420 cases per million and a case-fatality rate of 4–6%. 11-13 Most patients admitted have mild or moderate forms, which are self-limiting and do not benefit from antibiotics.14-16 Severe acute pancreatitis, however, is life-threatening, characterized by pancreatic necrosis,14 which can progress to infected necrosis. This is the main cause of complications and mortality, which has contributed to the widespread over prescription of antibiotics for its management. 14,17

In the current clinical practice, there is no consensus on the start of antibiotic therapy in patients with no bacterial culture test. Studies show wide range (31-82%) of antibiotic use frequency in acute pancreatitis patients, despite international guidelines recommending against the use of prophylactic antibiotics. It has been shown that although only about 5% patients with acute pancreatitis develop infection, almost 77% receive antibiotics, mostly on a preventive basis.17-21

Almost 77% receive antibiotics
But only 5% develop pancreatic infection

Siriwardena et al. have shown in a recent randomized controlled prospective study that a procalcitonin- aided algorithm could significantly reduce unnecessary antibiotic exposure in acute patients from 62% to 45%.22

Significant reduction of ABX prescriptions
Rational use of antibiotics in acute pancreatitis

Colorectal surgery and anastomotic leakage

Anastomotic leakage is one of the most dreaded complications after colorectal surgery and often leads to fatal outcomes. Several studies have shown that procalcitonin has a high negative predictive value to rule out anastomotic leakage on postoperative days 3 to 6.23-26

Secondary peritonitis

In postoperative patients with secondary peritonitis, PCT-aided algorithm can help to safely reduce the antibiotic duration.27-28

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References
 

  1. European Centre for Disease Prevention and Control. Surveillance of surgical site infections in Europe, 2008–2009. Stockholm: ECDC; 2012 [cited 2021Mar17]. Available here.

  2. World Health Organization. Global guidelines for the prevention of surgical site infection. World Health Organization; 2016.

  3. Anderson DJ. Surgical site infections. Infectious Disease Clinics. 2011 Mar 1;25(1):135–53.

  4. Meisner et al., Crit Care. 2006 Feb;10(1):R1. doi: 10.1186/cc390.

  5. Chromik AM, Endter F, Uhl W, Thiede A, Reith HB, Mittelkötter U. Pre-emptive antibiotic treatment vs ‘standard’treatment in patients with elevated serum procalcitonin levels after elective colorectal surgery: A prospective randomised pilot study. Langenbecks Arch Surg. 2006 Jun;391(3):187–94.

  6. Amour J, Birenbaum A, Langeron O, Le Manach Y, Bertrand M, Coriat P, et al. Influence of renal dysfunction on the accuracy of procalcitonin for the diagnosis of postoperative infection after vascular surgery. Crit Care Med. 2008 Apr 1;36(4):1147–54.

  7. Maravić-Stojković V, Lausević-Vuk L, Jović M, Ranković A, Borzanović M, Marinković J. Procalcitonin-based therapeutic strategy to reduce antibiotic use in patients after cardiac surgery: A randomized controlled trial. Srp Arh Celok Lek. 2011;139(11–12):736–42.

  8. Hochreiter M, Köhler T, Schweiger AM, Keck FS, Bein B, von Spiegel T, et al. Procalcitonin to guide duration of antibiotic therapy in intensive care patients: a randomized prospective controlled trial. Critical Care. 2009 Jun;13(3):1–7.

  9. Uzzan B, Cohen R, Nicolas P, Cucherat M, Perret GY. Procalcitonin as a diagnostic test for sepsis in critically ill adults and after surgery or trauma: a systematic review and meta-analysis. Crit Care Med 2006. 2006 Jul 1;34(7):1996–2003.

  10. Sartelli et al. World Journal of Emergency Surgery (2024) 19:22 ; https://doi.org/10.1186/s13017-024-00552-9

  11. Omdal T, Dale J, Lile Åsa, Iversen KB, Flaatten H, Ovrebø K. Scand J Gastroenterol 2011; 46: 1389–98.

  12. Goldacre MJ, Roberts SE. Hospital admission for acute pancreatitis in an English population, 1963–98: database study of incidence and mortality. BMJ 2004; 328: 1466–69.

  13. Singla A, Csikesz NG, Simons JP, et al. National hospital volume in acute pancreatitis: analysis of the Nationwide Inpatient Sample 1998–2006. HPB (Oxford) 2009; 11: 391–97.

  14. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102–11.

  15. Wittau M, Mayer B, Scheele J, Henne-Bruns D, Dellinger EP, Isenmann R. Scand J Gastroenterol 2011; 46: 261–70.

  16. Villatoro E, Mulla M, Larvin M. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Databases Syst Rev 2010; 2010: CD002941.

  17. Working group, Pancreatology. 2013;13(4):e1–e15. doi: 10.1016/j.pan.2013.07.063

  18. Dijk et al., Gut 2017; 66(11): 2024–2032. https://doi.org/10.1136/gutjnl-2016-313592

  19. Párniczky et al., Pancreatology 2019;19(4): 488–499. https://doi.org/10.1016/j.pan.2019.04.003

  20. Tenner et al., Am J Gastroenterol. 2013;108(9): 1400–15; 1416. doi: 10.1038/ajg.2013.218

  21. Crockett et al., Gastroenterology. 2018;154(4):1096–1101. doi: 10.1053/j.gastro.2018.01.032

  22. Siriwardena et al., Lancet Gastroenterol Hepatol 2022; 7(10): 913–921. https://doi.org/10.1016/S2468-1253(22)00212-6

  23. Italian ColoRectal Anastomotic Leakage (iCral) Study Group, BJS Open Jun 2020, doi: 10.1002/bjs.50269

  24. Xu et al., Int J Surgery Apr 2022; doi: 10.1016/j.ijsu.2022.106952

  25. Giacaglia et al., Ann Surgery, May 2016; doi: 10.1097/SLA.0000000000001365

  26. Giacaglia et al., J Crit Care, Aug 2014; doi: 10.1016/j.jcrc.2014.03.036