Antimicrobial management of intra-abdominal infections: an Italian multidisciplinary Consensus Conference

In a paper recently published in the World Journal of Emergency Surgery, an Italian multidisciplinary group of healthcare professionals promoted a Consensus Conference on the antimicrobial management of intra-abdominal infections (IAIs).

IAIs are common surgical emergencies, representing an important cause of morbidity and mortality across global hospital settings. The cornerstones of IAIs management include timely diagnosis, adequate source control, early and appropriate antimicrobial therapy, and quick physiological stabilization through intravenous fluid therapy and vasopressor agents, especially in critically ill patients.

Optimizing antimicrobial therapy is of utmost importance to improve treatment effectiveness, increase patient safety, minimize the risk of selecting antimicrobial resistant microorganisms, and reduce the risk of opportunistic infections, such as Clostridioides difficile.

The Consensus Conference was promoted by the Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use which included diverse healthcare professionals: not only surgeons, but also infectious disease specialists, microbiologists, clinical pharmacologists, hospital pharmacists, emergency medicine specialists, intensivists, radiologists, and public health specialists.

After focusing on the general principles of diagnosis and treatment of IAIs, a list of relevant clinical questions was constructed to investigate the topic. Concerning the antimicrobial management of IAIs, basic subjects were faced, such as the optimal timing to start an antibiotic therapy, its reassessment based on the results of microbiological culture and susceptibility testing, its optimal duration, daily doses and modality of administration, without forgetting to discuss antifungal treatment, as well.

Following the best scientific evidence from PubMed, EMBASE Library and experts’ opinions, the panel produced 23 recommendation statements for the antimicrobial therapy of IAIs. They were planned and graded according to the GRADE hierarchy of evidence. Using a Delphi approach, a consensus was reached for each statement.

In the last section of the paper, 8 clinical diagnostic-therapeutic pathways for the most common IAIs were presented. The document was endorsed by the Italian Society of Surgery.

The authors concluded that an effective antimicrobial strategy for managing IAIs requires a correct balance between two elements: optimizing empiric therapy to improve clinical outcomes, and curbing excessive antimicrobial use to mitigate the emergence of multidrug-resistant strains.

Reference

Sartelli M, Tascini C, Coccolini F, Dellai F, Ansaloni L, Antonelli M, et al. Management of intra-abdominal infections: recommendations by the Italian council for the optimization of antimicrobial use. World J Emerg Surg. 2024 Jun 8;19(1):23.

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

Infection prevention and management in surgery: a global declaration

In a paper recently published in the World Journal of Emergency Surgery, seven surgical societies around the world shared an important declaration.

The authors – expert physicians representing the societies involved in this alliance – highlighted the threat posed by antimicrobial resistance (AMR), and the importance to prevent and manage infections appropriately across the surgical pathway.

The Global Alliance for Infections in Surgery (GAIS), the World Society of Emergency Surgery (WSES), the Surgical Infection Society (SIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), the American Association for the Surgery of Trauma (AAST), and the Panamerican Trauma Society (PTS) participated in the realization of this document.

The goal was to raise awareness among surgeons about AMR by focusing on the importance of actively participating in this challenge.

Surgeons really play a pivotal role in prevention and management of infections in their daily practice. Indeed, they are primarily responsible for preventing hospital-acquired infections, particularly surgical site infections. Moreover, they are prescribers of antibiotics, both for prophylaxis and therapy.

Nevertheless, among them adequate infection prevention and control (IPC) measures, and appropriate antibiotic prescribing practices are often disregarded. Why?

In healthcare facilities around the world, cultural, contextual, and behavioural determinants can influence surgeons’ clinical practice. Furthermore, other factors – such as the fear of clinical failure, time pressure, or organizational contexts – can limit their adherence to IPC procedures and antibiotic prescribing practices.

According to the authors, surgeons in hospital settings should be aware of their role and responsibility, and follow the fundamental principles for correct infection prevention and management across the surgical pathway.

***Fundamental principles for correct infect*****ion prevention and management across the surgical pathway**
*[Adapted from Figure 1 in Ref. 1].*

Changing clinical behaviour is extremely challenging.

A collaborative and multidisciplinary approach is paramount to optimize individual patients’ outcomes and overall healthcare delivery. Each healthcare provider of the team has to participate, and be responsible for its own contribution to patient care.

The authors concluded calling all surgeons around the world to take part in this global cause, by pledging support for this declaration, and accepting responsibility for maintaining the effectiveness of current and future antibiotics.

Reference

Sartelli M, Coccolini F, Ansaloni L, Biffl WL, Blake DP, Boermeester MA, Coimbra R, Evans HL, Ferrada P, Gkiokas G, et al. Declaration on infection prevention and management in global surgery. World J Emerg Surg. 2023 Dec 6;18(1):56.

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

Optimal antibiotic use in hospital settings: ten golden rules

An important article has been recently published in the World Journal of Emergency Surgery.

A position paper, developed by an international multidisciplinary task force of experts, the WARNING collaborators, whose objective is to raise awareness of antimicrobial resistance (AMR), and improve antibiotic prescribing practices worldwide.

This document outlines ten axioms, or “golden rules”, that healthcare professionals should follow in their clinical practice for the appropriate use of these medications in hospital settings.

Antibiotics are life-saving medications, and therefore ensuring their correct prescription is an essential aspect of good clinical practice. The excessive and inappropriate antibiotic use is a main driver of AMR. However, in many regions of the world, there is not only overuse and misuse of antibiotics but also underuse. It is paramount to narrow the gap between excess and access.

As a matter of fact, optimising antibiotic prescribing implies improved treatment effectiveness and patient safety, minimises the risk of antibiotic-associated infections (e.g., Clostridioides difficile infection), and the selection and spread of antibiotic-resistant bacteria in patients within and across hospitals, countries, and globally.

In January 2023, the Global Alliance for Infections in Surgery established an international multidisciplinary task force to write and share a document on the need for appropriate use of antibiotics in hospitals to curb the spread of AMR.

Overall, 295 healthcare professionals with different backgrounds from 115 countries joined the WARNING (Worldwide Antimicrobial Resistance National/International Network Group) project.

In the final document, the ten golden rules for optimal antibiotic use in hospital settings have been described. They focus not only on the appropriate prescription of antibiotics, but also on the importance of Infection Prevention and Control, source control, monitoring and surveillance tools, education and awareness, and Antimicrobial Stewardship Programs.

**The 10 golden rules for optimal antibiotic use in hospital settings** [Adapted from Figure 1 in Ref. 1].

This document confirms the mission of the Global Alliance for Infections in Surgery, promoting standards of care in managing infections in surgery through a multidisciplinary and cohesive approach.

As the authors conclude, the appropriate use of antibiotics should be integral to good clinical practice, and these precious medications should be considered as a public good on the verge of scarcity.

Therefore, it is a global collective responsibility to preserve antibiotics, and avoid future deaths caused by multidrug resistant infections.

Reference

Worldwide Antimicrobial Resistance National/International Network Group (WARNING) Collaborators. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. World J Emerg Surg. 2023 Oct 16;18(1):50.

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