Author: infectionsinsurgery

The mission of the Global Alliance for Infections in Surgery is to educate health care providers promoting the standards of care in managing infections in surgery worldwide.

Necrotizing soft tissue infections in adult patients: a position statement by the Global Alliance for Infections in Surgery

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Necrotizing soft tissue infections (NSTIs) are acute and rapidly progressive infections, resulting in extensive tissue destruction due to the production of toxins which cause tissue damage, ischemia and necrosis. Consequently, NSTIs are often associated with signs of severe systemic toxicity and progressive multiorgan failure.

An early diagnosis – based on clinical evaluation, laboratory and radiological tests – together with a prompt surgical intervention, and an appropriate antibiotic treatment are essential elements to reduce mortality and improve outcomes.

However, despite important advances in critical care medicine over the last few decades, the mortality rate is still high, and survivors are at a significant risk of long-term morbidity. Indeed, after a prolonged hospitalization, multiple dressing changes and surgical procedures, the survivors have to face continued physical therapy to regain functional independence. A multidisciplinary approach should focus not only on survival but also on long-term functional outcomes.

In a paper recently e-published (ahead-of-print) in the Journal of Trauma and Acute Care Surgery, Massimo Sartelli, together with an international and multidisciplinary research group of physicians, signed an evidence-based position statement, whose main objective was to describe the best practices for the first-line management of NSTIs in adult patients.

The working group, representing the Global Alliance for Infections in Surgery, included physicians from several different disciplines: general and emergency surgeons, intensive care specialists, and infectious diseases specialists.

A comprehensive literature search of pertinent documentation was performed using PubMed and Google Scholar, and articles published in English between January 2010 and August 2024 were identified. Evidence quality has been graded high, moderate, low, or very low according to the GRADE methodology. The strength of the recommendations has been classified as weak or strong. The final document was approved by each member to ensure consensus.

First of all, the authors declare that a multidisciplinary collaboration is mandatory for the first-line management of NSTIs. Diagnosis should be made as soon as possible. Due to the quick progression of the inflammatory process, a rapidly progressive soft-tissue infection should always raise suspicion of NSTI.

Early source control is one of the cornerstones of treatment in patients with NSTIs. Surgical debridement with complete removal of necrotic tissue is essential to decrease mortality and other complications, and should be performed as soon as possible within 6 hours after presentation, supporting the concept that earlier surgery is performed, better is the outcome.

Moreover, antibiotic treatment and supportive treatment in managing NSTIs must be prompt and aggressive to halt the progression of the inflammatory process. Post-operative wound care and along-term and multidisciplinary management of the patient must always be considered. Finally, a conclusive section is dedicated to Fournier’s gangrene.

The authors conclude that public health policies promoting education among both healthcare providers and patients, and expert centres, together with systematic data collection could lead to better outcomes for NSTIs in the future.

Reference

A healthier world for all: is it possible?

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Today the world is facing a crisis that threatens the fundamental pillars of public health, scientific integrity and social stability. These challenges can exacerbate global inequalities, jeopardise health security and undermine the progress achieved through years of international collaboration. It is crucial that health scientists are aware of these interconnected challenges and respond united and determined.

For these reasons, in a paper recently published in the World Journal of Emergency Surgery, a viewpoint declaration was signed by the Global Consortium for Solidarity to Overcome Challenges, Restore Trust and Advance Science for a Sustainable Future. This group included 366 healthcare workers and scientists from 119 countries from across all continents and belonging to numerous disciplines.

The paper aims to highlight the urgent need for global solidarity and collective action to address several global health challenges.

The authors begin their dissertation by focusing on the importance of investing in resilient healthcare systems, considering the vulnerability and fragility of global public health systems revealed by the COVID-19 pandemic. Moreover, the rapid process of globalisation has challenged traditional border-based control mechanisms, calling for new approaches to governing the globalization of public health.

Then, considering climate change as a public health emergency is essential, as well as evaluating the challenges of infectious diseases and antimicrobial resistance (AMR). In particular, AMR is considered by the authors as a global scientific, human, and economic challenge. They wish for a new research model on AMR that promotes collaboration and integrates knowledge across disciplines, ensuring a holistic approach and universal impact. Therefore, these objectives can be achieved adopting a One Health approach to combat infectious diseases and AMR.

Moreover, wars must be considered as public health emergencies. They have devastating effects on health, requiring immediate and coordinated global response. The healthcare community must play a leading role in preventing wars and promoting peace.

Among the challenges to be faced today, the authors included also combating false and misleading information. False narratives regarding health can damage public trust in science. Scientists must actively involve the public and communicate their findings in transparent and accessible ways. Furthermore, rethinking the quality and integrity of scientific research is essential as well.

Regulating artificial intelligence use in healthcare should be a priority, wisely considering its opportunities and challenges in a balance between innovation and ethical oversight. Finally, the importance of strengthening the global health governance is clearly underlined.

The authors conclude that scientists, clinicians, and healers can be stronger and better in restoring global trust and confidence only if they are united by a single but shared goal: a healthier world for all.

Reference

Sartelli M, Mossialos E, Coccolini F, et al. Global health at crossroads: uniting together to overcome challenges, restore trust and advance priorities for a sustainable future. World J Emerg Surg. 2025;20:84.

Antibiotics for Intra-Abdominal Infections: When, Which, How and How Long?

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Intra-abdominal infections (IAIs) are among the most challenging problems in surgical practice, ranging from uncomplicated appendicitis to life-threatening peritonitis. IAIs require prompt diagnosis, timely surgical intervention, and appropriate antimicrobial therapy.

Antibiotics are essential in IAIs management. For years, an empirical broad-spectrum approach, often with prolonged courses of multiple agents, has been the default response to IAIs. This approach certainly saved lives. However, it has promoted the selection of multidrug-resistant organisms.

Prescribing antibiotics in IAIs is challenging: it requires a balance between urgency and precision, between lifesaving therapy and the long-term threat of antimicrobial resistance (AMR). Antibiotic therapy should be individualised and tailored on the patient’s clinical conditions and the local epidemiology.

In community-acquired IAIs, narrow-spectrum coverage is often sufficient, avoiding unnecessary exposure to carbapenems or anti-pseudomonal agents. In contrast, healthcare-associated infections, especially in patients with previous antibiotic exposure or serious illness, may need a broader empiric approach, followed by de-escalation once cultures clarify the microbiologic picture.

For these reasons, in a narrative review recently published in Antibiotics, Massimo Sartelli and his collaborators tried to answer four questions.

When should antibiotics be used in patients with IAIs? Which antibiotics should be selected? How should they be managed? How long should they be administered in patients with IAIs?

The authors concluded that advances in antibiotic agents, optimised pharmacokinetics and pharmacodynamics strategies, and stewardship-driven de-escalation provide opportunities to improve efficacy while preserving future antibiotic utility in an era of increasing AMR.

Reference

Sartelli M, Palmieri M, Labricciosa FM. Antibiotics for Intra-Abdominal Infections: When, Which, How and How Long? Antibiotics. 2025;14(11):1127. 

Personalised approaches to optimise outcomes in patients with intra-abdominal infections

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Intra-abdominal infections (IAIs) represent an important cause of morbidity and mortality across the globe.

Optimal management of complicated IAIs requires a personalised approach based on a prompt and precise diagnosis, and the implementation of appropriate interventions, including timely and adequate source control, appropriately tailored antimicrobial therapy based on pharmacokinetic and pharmacodynamic principles and antimicrobial stewardship, and hemodynamic support with intravenous fluids and vasopressors for critically ill patients.

In a narrative review recently published in the Journal of Clinical Medicine, Massimo Sartelli and colleagues described and analysed five basic factors to be always assessed for the optimal management of patients with complicated IAIs.

An individualised strategy should always consider the anatomical extent of infection, the origin of the infection, the patient’s clinical condition, the suspected microorganism involved and risk factors for antimicrobial resistance, and the host’s immune status.

The authors concluded that a careful and continuous assessment of these factors is essential to optimise outcomes for patients with complicated IAIs.

Reference

Sartelli M, Coccolini F, Labricciosa FM, et al. Personalized Approaches to Patients with Intra-Abdominal Infections. J Clin Med. 2025;14(21):7774.

Optimizing surgical antibiotic prophylaxis in the era of antimicrobial resistance: a position paper

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Antimicrobial resistance (AMR) represents a serious threat to global health because antibiotics are losing effectiveness in both prevention and treatment of infections. The rising incidence of multidrug-resistant organisms (MDROs) challenges the efficacy of conventional surgical antibiotic prophylaxis (SAP) regimens.

Addressing this issue requires a re-examination of perioperative protocols, with attention to individual patient risk factors for MDRO colonization. Therefore, a targeted SAP approach should be considered when MDROs represent a significant surgical site infection risk. Thus far, limited evidence provides guidance on SAP selection in high-risk patients.

For these reasons, a position paper has been recently publishedin Pathogens by the Italian Multidisciplinary Society for the Prevention of Healthcare-Associated Infections (SIMPIOS). Following the best scientific evidence from PubMed and EMBASE Library a multidisciplinary working group produced 15 recommendation statements to optimize SAP in a context of AMR. They were graded according to the GRADE hierarchy of evidence. Using a Delphi approach, statements reaching ≥80% agreement were approved as strong recommendations.

This position paper is structured in three sections.

The first one widely reviewed the core principles for appropriate SAP. Then, the second section examined screening, decolonization, and targeted SAP in patients colonized with MDROs focusing separately on Gram-positive bacteria (methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant enterococci [VRE]), and Gram-negative bacteria (extended-spectrum beta-lactamase [ESBL]-producing and carbapenem-resistant Enterobacterales [CRE]).

The third section discussed the barriers to changing surgeons’ prescribing behaviours, focusing on surgeons’ awareness and dynamics within surgical teams that influence antibiotic prescribing practices. To track adherence and improvement in SAP, the authors listed the key performance indicators, and suggested a checklist, too.

Finally, they summarized all the 15 recommendation statements expressed by the multidisciplinary working group in order to provide practical guidance for optimising SAP in the context of an AMR era.

The authors concluded that in the AMR era the goal is to ensure that SAP remains effective in preventing infections while minimizing unnecessary antibiotic exposure. This can be achieved balancing patient safety with stewardship principles, tailoring SAP to epidemiological risk, and promoting a culture of shared responsibility across the surgical pathway.

Reference

  1. Sartelli M, Labricciosa FM, Casini B, et al. Optimizing Surgical Antibiotic Prophylaxis in the Era of Antimicrobial Resistance: A Position Paper from the Italian Multidisciplinary Society for the Prevention of Healthcare-Associated Infections (SIMPIOS). Pathogens. 2025;14(10):1031. 

Epidemiological analysis of intra-abdominal infections in Italy: the IRIS study

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Intra-abdominal infections (IAIs) are common and serious surgical emergencies. Over the past few years, an increase in antimicrobial resistance (AMR) associated with IAIs has been observed worldwide, responsible for a significant increase in morbidity and mortality rates, and overall healthcare costs. In order to improve the quality of treatment, it is essential to recognize the underlying local epidemiology, clinical implications, and appropriate management of AMR.

In a paper recently published in the World Journal of Emergency Surgery, a prospective, observational, nationwide, multicentre study was conducted to investigate the epidemiology and initial management of complicated IAIs (cIAIs) in Italy.

The IRIS study (Italian Register of Complicated Intra-abdominal InfectionS) included 4,530 consecutively hospitalized patients – older than 16 years of age – from 23 different Italian hospitals, between May 1, 2021 and April 31, 2023, with diagnosis of cIAIs undergoing surgery, interventional drainage or conservative treatment.

Overall, 70.9% of the cases were community acquired infections, the predominant type of infection for all the diagnosis. The majority of healthcare-associated infections were represented by colonic perforation and diverticulitis (28.3%), small bowel occlusion (19%) and intestinal ischemia (18%). At presentation, 27.8% of patients had a septic shock. The overall mortality rate was 5.13%, and 16.5% of patients required admission to Intensive Care Unit.

Microbiological samples were collected from 3,208 (70.8%) patients; 48.8% of intrabdominal samples resulted positive. Not surprisingly, the major pathogen involved in IAIs was E. coli (45.6%). Remarkably, in 29% of the cases microbiological samples were not collected.

During hospital stay, an empiric antimicrobial therapy was administered in 78.4% of patients. Amoxicillin/clavulanate was the most common antibiotic used (e.g., in 30.1% appendicitis, 30.5% of cholecystitis, and 55% small bowel perforation), followed by piperacillin/tazobactam (e.g., in 13.3% colonic perforation and diverticulitis, 22.6% cholecystitis, 28.6% pancreatitis). Empiric antifungal therapy was administered in 2.6% of patients with no sign of sepsis, 3.1% of patients with clinical sign of sepsis and 4.1% of patients with septic shock. Azoles were the most used antifungals in patients that received empiric antifungal therapy.

The authors concluded that antibiotic stewardship programs and correct antimicrobial and antifungal prescription campaigns are needed to further improve the appropriateness of drug usage and reduce the burden of AMR. This will contribute to better care and treatment for the next generations.

Reference

  1. Coccolini F, Brogi E, Ceresoli M, et al. Epidemiological analysis of intra-abdominal infections in Italy from the Italian register of complicated intra-abdominal infections—the IRIS study: a prospective observational nationwide study. World J Emerg Surg. 2025;20:22.

Antimicrobial peptides and their coatings to counter multidrug-resistant clinical pathogens

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Antimicrobial resistance (AMR) is a growing public health issue. Unfortunately, microorganisms use several mechanisms to inactivate antimicrobials, making ineffective traditional therapies currently employed. Therefore, discovering novel antimicrobial agents is essential to successfully address this global challenge.

In a paper recently published in Antibiotics, a multidisciplinary group of investigators focused on non-antibiotic antimicrobial strategies, particularly on the use of antimicrobial peptides, as potential strategies for managing multidrug resistant (MDR) pathogens.

The authors started their narrative review discussing the alternative non-antibiotic approaches for the prevention and control of MDR pathogens, namely bacteriophage therapy, probiotics, immunotherapies, photodynamic therapy, essential oils, nanoparticles, and antimicrobial peptides (AMPs).

After summarising the benefits and limitations of these different approaches, the authors focused on AMP mimetics and strategies to enhance AMP activity, the mechanisms of action of AMPs, and the reduction in virulence factors by peptidomimetics.

Specific subsections of the paper concerned antifungal, antiviral and antiparasitic peptides and their mimetics. Moreover, the authors provided an overview of antimicrobial coatings using AMPs and their relevance in medical settings. Finally, they presented several additional strategies for attachment and functionalization.

AMPs are promising alternative antimicrobial agents to tackle AMR. Although their clinical potential is limited by different challenges, their stability, safety, and efficacy can be enhanced, making them more appropriate for clinical applications.

AMPs and their synthetic mimetics represent a new frontier in antimicrobial coatings against bacterial and viral pathogens. Indeed, they are a precious tool in the fight against infectious diseases, being able to disrupt microbial membranes and prevent pathogen adhesion.

The authors concluded that further research should be performed in the future, focusing on in vivo studies to evaluate both the antimicrobial and anti-virulence efficacy of these molecules.

Reference
  1. Mishra SK, Akter T, Urmi UL, Enninful G, Sara M, Shen J, Suresh D, Zheng L, Mekonen ES, Rayamajhee B, Labricciosa FM, Sartelli M, Willcox M. Harnessing Non-Antibiotic Strategies to Counter Multidrug-Resistant Clinical Pathogens with Special Reference to Antimicrobial Peptides and Their Coatings. Antibiotics. 2025;14(1):57.

Prevention and control of healthcare-associated infections: the first principle of every antimicrobial stewardship program

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

The misuse and overuse of antimicrobials are among the main drivers in the development of drug-resistant pathogens, and the appropriate use of these precious medications is paramount to preserve them for future generations to come. However, healthcare professionals should always keep in mind that also an inadequate infection prevention and control contributes considerably to the emergence and spread of antimicrobial resistance (AMR).

AMR is closely related to healthcare-associated infections (HAIs): the management of patients with HAIs frequently requires the administration of broader spectrum antibiotic regimens due to the higher risk of acquiring multidrug-resistant organisms. For this reason, even before using antimicrobials correctly, preventing the occurrence and controlling the spread of HAIs in healthcare facilities is essential. It should be considered the first principle of an appropriate antimicrobial stewardship program in every hospital worldwide.

In a paper recently published in Antibiotics, an international working group of physicians defined the most important measures to prevent and control HAIs in hospital settings.

In this narrative review, the authors presented seven measures that all healthcare workers must know and support. They focused their attention not only on the pivotal role of hand hygiene and the prevention of HAIs, but also on the importance of an effective environmental hospital hygiene, the implementation of surveillance systems, and patients’ screening, decolonization, isolation and cohorting. Finally, they did not forget to discuss about adapting evidence-based practices to the local context, and promoting safety culture.

The authors hope that this document can contribute to raise awareness among healthcare professionals about all issues associated with HAIs, and the need to embrace a personal involvement in the strategies that can help reduce their occurrence.

Fewer microorganisms there will be in our hospitals, fewer antimicrobials we will use. Fewer HAIs will develop in our hospitals, fewer broad-spectrum antibiotics we will have to use to combat multidrug-resistant organisms.

Reference

  1. Sartelli M, Marini CP, McNelis J, Coccolini F, Rizzo C, Labricciosa FM, Petrone P. Preventing and Controlling Healthcare-Associated Infections: The First Principle of Every Antimicrobial Stewardship Program in Hospital Settings. Antibiotics. 2024;13(9):896.

Antibiotic prophylaxis in trauma patients: indications for an optimal management

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

By definition, antibiotic prophylaxis (AP) is the use of antibiotics to prevent infections at the site of injury and/or surgical site. It must be administered close to the time of procedure initiation or time of injury, and based on its pharmacodynamics and pharmacokinetics.

The World Health Organization provides strong recommendations on the administration of AP. Nevertheless, AP is often used inappropriately worldwide.

In polytrauma patients, the presence of several injuries implicates multiple potential risks of infections. In these situations, antibiotics – for treatment or prophylaxis – are frequently used without a defined rationale following recommended guidelines. The difficulty of standardizing definitions and approaches leads to this heterogeneous practice.

Ideally, AP in trauma should be specifically targeted for each patient. AP should reduce the risk of infections due to injuries, decrease the selection of multi-resistant bacterial strains, and have no adverse effects.

The fear of infections must not drive AP prescription. Infections must be treated only when present, and their prevention must occur based on specific evidence-based indications.

To address this lack of precise indications, an international group of experts – representing five surgical societies around the world – has recently published in the Journal of Trauma and Acute Care Surgery a paper providing recommendations for an optimal management of AP in trauma patients.

The Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and the World Society of Emergency Surgery participated in the realization of this important document.

A computerized search was performed in different databases (MEDLINE, Scopus, EMBASE), including citations published between January 2000 to May 2023. The grade of recommendation, defined as strong, moderate, and weak, was established, considering the Oxford model. Through the Delphi process, different issues were discussed by the experts in several rounds. After three rounds, the process led to 100% agreement on all statements.

The article suggests the recommendations regarding the use of AP in head and brain trauma, maxillofacial trauma, thoracic and abdominal trauma, open fractures, burns, and skin wounds and bites.

The authors conclude that AP must be used only when it is indicated. Its overuse has no beneficial effects on patients. On the contrary, it has several potential drawbacks. A tailored infection risk calculation for each patient should be always performed, keeping in mind that a correct source control plays a central role in infection prevention.

Reference

  1. Coccolini F, Sartelli M, Sawyer R, Rasa K, Ceresoli M, Viaggi B, Catena F, Damaskos D, Cicuttin E, Cremonini C, et al. Antibiotic prophylaxis in trauma: Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and World Society of Emergency Surgery guidelines. J Trauma Acute Care Surg. 2024 Apr 1;96(4):674-682.

Intra-abdominal Infections Survival Guide: a Position Statement by the Global Alliance for Infections in Surgery

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

An interesting article has been recently published in the World Journal of Emergency Surgery. An evidence-based position statement signed by a multidisciplinary working group of experts, whose main objective was to describe the best practices for complicated intra-abdominal infections (IAIs) management.

The working group, representing the Global Alliance for Infections in Surgery, included physicians from several different disciplines: general and emergency surgeons, intensive care specialists, and infectious diseases specialists.

A comprehensive literature search of pertinent scientific evidence was performed using PubMed and Google Scholar, and articles published in English between January 2010 and December 2023 were identified to formulate 28 statements. Evidence quality has been graded high, moderate, low, or very low according to the GRADE methodology. For each statement, consensus among the experts was reached using a Delphi approach. Statements were endorsed as a strong recommendation with agreement by ≥ 80% of participating experts. The final document was approved by each working group member to ensure consensus.

Several factors of importance in the management of complicated IAIs were listed.

First of all, the origin of the infection must be taken into account. Indeed, the term “intra-abdominal infections” includes several different pathologic conditions ranging in severity from uncomplicated appendicitis to diffuse faecal peritonitis. The origin of the infection should be always investigated for treatment planning. Achievement of source control is of utmost importance in the management of complicated IAIs.

Assessing the anatomic extent of infection is equally important to define the treatment approach. In uncomplicated IAIs, the infectious process only involves a single organ, while in complicated IAIs, it extends beyond, into the peritoneal cavity, leading to abscess formation or diffuse peritonitis. This classification does not describe patients’ complexity, but in its simplicity, defining the extension of the infectious process identifies those patients who need both source control and antimicrobial therapy.

Moreover, taking into account presumed pathogens involved and risk factors for antimicrobial resistance is crucial. Initial antimicrobial therapy for complicated IAIs is typically empiric in nature because standard microbiologic data and susceptibility results generally require 24-72 hours after peritoneal fluid specimen collection. For these reasons, an accurate patient stratification is crucial to optimize empiric antimicrobial therapy.

Finally, clinical conditions and host immune status have to be carefully considered when managing a patient with a complicated IAI.

The authors concluded that complicated IAIs are conditions sometimes difficult to manage, and available treatment options should be always assessed to optimize the management of patients with complicated IAIs.

Reference

  1. Sartelli M, Barie P, Agnoletti V, Al-Hasan MN, Ansaloni L, Biffl W, et al. Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery. World J Emerg Surg. 2024 Jun 8;19(1):22.