title: Dynamic changes of microbial flora and therapeutic consequences in persistent peritonitis.
abstract: BACKGROUND
  Persistent peritonitis is a frequent complication of secondary peritonitis requiring additional reoperations and antibiotic therapy. This situation raises specific concerns due to microbiological changes in peritoneal samples, especially the emergence of multidrug-resistant (MDR) strains. Although this complication has been extensively studied, the rate and dynamics of MDR strains have rarely been analysed.
  
  
  METHODS
  We compared the clinical, microbiological and therapeutic data of consecutive ICU patients admitted for postoperative peritonitis either without subsequent reoperation (n = 122) or who underwent repeated surgery for persistent peritonitis with positive peritoneal fluid cultures (n = 98). Data collected on index surgery for the treatment of postoperative peritonitis were compared between these two groups. In the patients with persistent peritonitis, the data obtained at the first, second and third reoperations were compared with those of index surgery. Risk factors for emergence of MDR strains were assessed.
  
  
  RESULTS
  At the time of index surgery, no parameters were able to differentiate patients with or without persistent peritonitis except for increased severity and high proportions of fungal isolates in the persistent peritonitis group. The mean time to reoperation was similar from the first to the third reoperation (range: 5 to 6 days). Septic shock was the main clinical expression of persistent peritonitis. A progressive shift of peritoneal flora was observed with the number of reoperations, comprising extinction of susceptible strains and emergence of 85 MDR strains. The proportion of patients harbouring MDR strains increased from 41% at index surgery, to 49% at the first, 54% at the second (P = 0.037) and 76% at the third reoperation (P = 0.003 versus index surgery). In multivariate analysis, the only risk factor for emergence of MDR strains was time to reoperation (OR 1.19 per day, 95%CI (1.08 to 1.33), P = 0.0006).
  
  
  CONCLUSIONS
  Initial severity, presence of Candida in surgical samples and inadequate source control are the major risk factors for persistent peritonitis. Emergence of MDR bacteria is frequent and increases progressively with the number of reoperations. No link was demonstrated between emergence of MDR strains and antibiotic regimens, while source control and its timing appeared to be major determinants of emergence of MDR strains.
authors.affiliation: Département d'Anesthésie Réanimation, Université Paris Diderot, APHP, CHU Bichat-Claude Bernard, 46, Rue Henri Huchard, Paris, 75018, France. philippe.montravers@bch.aphp.fr.
authors.forename: Philippe
authors.initials: P
authors.lastname: Montravers
authors.affiliation: Département d'Anesthésie Réanimation, Université Paris Diderot, APHP, CHU Bichat-Claude Bernard, 46, Rue Henri Huchard, Paris, 75018, France. guillaume.dufour@bch.aphp.fr.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Dufour
authors.affiliation: Département d'Anesthésie Réanimation, Université Paris Diderot, APHP, CHU Bichat-Claude Bernard, 46, Rue Henri Huchard, Paris, 75018, France. jean.guglielminotti@bch.aphp.fr.
authors.forename: Jean
authors.initials: J
authors.lastname: Guglielminotti
authors.affiliation: Département d'Anesthésie Réanimation, Université Paris Diderot, APHP, CHU Bichat-Claude Bernard, 46, Rue Henri Huchard, Paris, 75018, France. mathieu.desmard@bch.aphp.fr.
authors.forename: Mathieu
authors.initials: M
authors.lastname: Desmard
authors.affiliation: Université Paris Diderot, APHP, CHU Bichat-Claude Bernard, Laboratoire de Microbiologie, Paris, France. claudette.muller@bch.aphp.fr.
authors.forename: Claudette
authors.initials: C
authors.lastname: Muller
authors.affiliation: Département d'Anesthésie Réanimation, Université Paris Diderot, APHP, CHU Bichat-Claude Bernard, 46, Rue Henri Huchard, Paris, 75018, France. hamda.houissa@bch.aphp.fr.
authors.forename: Hamda
authors.initials: H
authors.lastname: Houissa
authors.affiliation: Département d'Anesthésie Réanimation, Université Paris Diderot, APHP, CHU Bichat-Claude Bernard, 46, Rue Henri Huchard, Paris, 75018, France. nicolas.allou@bch.aphp.fr.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Allou
authors.affiliation: Université Paris Diderot, APHP, CHU Bichat-Claude Bernard, Service de Chirurgie Générale, Paris, France. jean-pierre.marmuse@bch.aphp.fr.
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Marmuse
authors.affiliation: Département d'Anesthésie Réanimation, Université Paris Diderot, APHP, CHU Bichat-Claude Bernard, 46, Rue Henri Huchard, Paris, 75018, France. pascal.augustin@bch.aphp.fr.
authors.forename: Pascal
authors.initials: P
authors.lastname: Augustin
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001202:Ascitic Fluid / Q000382:microbiology; D002175:Candida / Q000302:isolation & purification; D024901:Drug Resistance, Multiple, Bacterial; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D010533:Peritoneal Lavage; D010538:Peritonitis / Q000209:etiology / Q000382:microbiology* / Q000628:therapy*; D011183:Postoperative Complications; D012086:Reoperation; D012307:Risk Factors; D018805:Sepsis / Q000382:microbiology / Q000628:therapy; D012720:Severity of Illness Index; D061665:Time-to-Treatment
chemical_list: D000900:Anti-Bacterial Agents