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| COMMENTARY AND OPINION |
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| Year : 2022 | Volume
: 1
| Issue : 1 | Page : 38-39 |
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Progress on the diagnosis and management of surgical infection: Dialogue with the world
Xiuwen Wu, Xing Chen, Jianan Ren
Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| Date of Submission | 09-Feb-2022 |
| Date of Decision | 02-Mar-2022 |
| Date of Acceptance | 26-Mar-2022 |
| Date of Web Publication | 17-Jun-2022 |
Correspondence Address:
Jianan Ren
Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing 210002
China
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wjsi.wjsi_1_22
How to cite this article:
Wu X, Chen X, Ren J. Progress on the diagnosis and management of surgical infection: Dialogue with the world. World J Surg Infect 2022;1:38-9 |
On December 17, 2021, the 12th Annual Meeting of Chinese Society of Surgical Infection and Intensive Care and the 7th Nanjing Zhongshan International Surgical Infection Forum were held online. Dialog with The World is a regular program which has been conducted since the 1st Nanjing Zhongshan International Surgical Infection Forum. This program is especially settled for international experts to communicate with Chinese surgeons. Due to COVID-19, the 2021 meeting adjusted to be virtual.
Jianan Ren from Jinling Hospital and Peige Wang from the Affiliated Hospital of Qingdao University served as moderators. Robert G. Sawyer from Western Michigan University School of Medicine, H. Kemal Rasa from Anadolu Medical Center, Peter M. Nthumba from AIC Kijabe Hospital, and Stijn de Jonge from Amsterdam UMC were invited. Chinese speakers included Hua Yang from the Second Affiliated Hospital of Army Medical University, Chaogang Fan from BenQ Medical Center, Shikuan Li from the Affiliated Hospital of Qingdao University, Huimin Yi from the Third Affiliated Hospital of Sun Yat-Sen University, Guosheng Gu from Anhui No. 2 Provincial People's Hospital, and Xiuwen Wu from Jinling Hospital.
The meeting mainly discussed recent progress on the diagnosis and management of surgical infection including intra-abdominal infection (IAI), surgical site infection, and skin and soft-tissue infection. This correspondence will briefly introduce the main content of the meeting.
| Source Control | |  |
The first topic would be measure for source control for IAI. Surgical operation and puncture drainage are commonly used measures for source control. Challenges come from the need for co-operation between surgeons and anesthesiologists. For critically ill patients with unstable hemodynamics, it is really difficult for surgeons to make decisions to perform or not to perform operations, as well as the timing of those procedures. Only aggressive team members may have the determination to take the risks to help these patients survive surgically. When facing near-death patients, surgeons may need to precisely evaluate the sources of infection, to persuade anesthesiologists to provide appropriate anesthesia and support, and to make the operation as short as possible. For some extreme cases, surgical treatment can be conducted in the intensive care unit if the anesthesiologist and surgeon are comfortable with a bedside procedure. However, to operate at the bedside may not be optimal, because the available equipment may be inadequate and the lighting is not good.
Recent controversy in the surgical approach of surgical infection lies in the use of open abdomen (OA) therapy. OA was initially applied to patients with severe abdominal trauma in the context of damage control surgery. Right now, its application has been extended to patients with severe IAI unrelated to trauma, working as the part of the procedure of rapid source control. This approach allows the patient to be returned to the intensive care unit as quickly as possible for further resuscitation and stabilization, knowing a subsequent operation will be performed to re-examine and close the abdomen. On the other hand, if a single operation can be done to achieve source control and to close the abdomen safely, a second procedure is unnecessary. At present, it is not clear how to tell who will benefit from each of these two approaches.
| Antibiotic Stewardship | | |
Antibiotic stewardship is especially important on surgical wards. However, antibiotics are often used inappropriately, specifically when unnecessary, when administered for excessive duration or given without consideration of pharmacokinetic principles. The misuse as well as prolonged use of antibiotics is widely accepted as a major driver of the selection of resistant pathogens in individual patients and for the continued development of antimicrobial resistance globally.
Currently used guidelines recommend a treatment course of 4–7 days for antibiotics, depending on the clinical response. Several clinical trials have suggested that with adequate source control, a shorter course of 3–5 days should suffice for cure. The appropriate duration of therapy or the indication for when therapy should be discontinued, however, remains unclear. Procalcitonin could be used for guiding antibiotic discontinuation in critically ill patients. However, the current guidelines suggest that for bloodstream infection, these drugs should be continued for at least 7 days after blood cultures become negative.
Most IAIs are mixed infections caused by aerobic and anaerobic bacteria. As the isolation and culture of anaerobic bacteria as well as its drug-sensitivity testing are time-consuming and sometimes inaccurate, the treatment of anaerobic bacteria is mostly empirical. Metronidazole is the first choice and the only nitroimidazole available for anti-anaerobic therapy in North America. Considering emerging metronidazole resistance and newly developed anti-anaerobic drugs, metronidazole may eventually be replaced by other nitroimidazoles in the management of IAIs. Morinidazole, ornidazole, and other anti-anaerobic agents as combination therapy have shown their efficacy and safety for IAI. Alternatively, monotherapy with an agent with aerobic and anaerobic activity, such as piperacillin-tazobactam or a carbapenem, may be chosen.
| Future Work | | |
Because of the COVID-19 epidemic, we have to consider new ways to communicate and share experiences. Meetings that could have been held offline now can only be held online. Communications among international surgeons are very necessary. Events like “Dialog with The World” are really good at making physicians think a little bit differently about how to do things. Surgeons' leadership, antibiotic stewardship, and resistance rate of metronidazole all require our further work.
The dialog is also a collaboration among the Chinese Society of Surgical Infection, the Surgical Infection Society-Europe, and the World Surgical Infection Society. Compared with the first two societies, the World Surgical Infection Society is very young, aiming to help improve global outcomes from surgical infections in resource-limited low- and middle-income countries. We hope this dialog can initiate more discussion on the diagnosis and management of surgical infections, and more research findings can be published here in the World Journal of Surgical Infection.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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