title: Factors Associated with the Development of Tertiary Peritonitis in Critically Ill Patients.
abstract: BACKGROUND
  Critically ill surgical patients remain at a high risk of adverse outcomes as a result of secondary peritonitis (SP). The risk is even higher if tertiary peritonitis (TP) develops. Factors related to the development of TP, however, are scarce in the literature. The main aim of our study was to identify factors associated with the development of TP in patients with SP in the intensive care unit (ICU), and also to report differences in microbiologic patterns and antibiotic therapy in patients with the two conditions.
  
  
  METHODS
  A prospective, observational study was conducted at our institution from 2010 to 2014. Baseline characteristics on admission, outcomes, microbiologic results, and antibiotic therapy were recorded for analysis.
  
  
  RESULTS
  We included 343 patients with SP, of whom TP developed in 185 (53.9%). Almost two-thirds (64.4%) were male; mean age was 63.7 ± 14.3 years, and mean APACHE was 19.4 ± 7.8. In-hospital death was 42.6% (146). Multivariable analysis showed that longer ICU stay (odds ratio [OR]: 1.019; 95% confidence interval [CI]: 1.004-1.034; p = 0.010), urgent operation on hospital admission (OR: 3.247; 95% CI: 1.392-7.575; p = 0.006), total parenteral nutrition (TPN) (OR: 3.079; 95% CI: 1.535-6.177; p = 0.002) and stomach-duodenum as primary infection site (OR: 4.818; 95% CI: 1.429-16.247; p = 0.011) were factors associated with the development of TP, whereas patients with localized peritonitis were less prone to have TP develop (OR: 0.308; 95% CI: 0.152-0.624; p = 0.001). Higher incidences of Candida spp. (OR: 1.275; 95% CI: 1.096-1.789; p = 0.016), Enterococcus faecium (OR: 1.085; 95% CI: 1.018-1.400; p = 0.002), and Enterococcus spp. (OR: 1.370; 95% CI: 1.139-1.989; p = 0.047) were found in TP, and higher rates of cephalosporin use in SP (OR: 3.51; 95% CI: 1.139-10.817; p = 0.035).
  
  
  CONCLUSIONS
  Complicated peritonitis remains a cause of a high numbers of deaths in the ICU. The need for TPN, urgent operation on hospital admission, and particularly surgical procedures in the proximal gastrointestinal tract were factors associated with development of TP and may potentially help to identify patients with SP at risk for development of TP. Physicians should be aware concerning multi-drug-resistant germs when treating these patients.
authors.affiliation: 1 Intensive Care Department, Hospital Universitari de Bellvitge , IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge). L'Hospitalet de Llobregat, Barcelona, Spain .
authors.forename: Josep
authors.initials: J
authors.lastname: Ballus
authors.affiliation: 1 Intensive Care Department, Hospital Universitari de Bellvitge , IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge). L'Hospitalet de Llobregat, Barcelona, Spain .
authors.forename: Juan C
authors.initials: JC
authors.lastname: Lopez-Delgado
authors.affiliation: 1 Intensive Care Department, Hospital Universitari de Bellvitge , IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge). L'Hospitalet de Llobregat, Barcelona, Spain .
authors.forename: Joan
authors.initials: J
authors.lastname: Sabater-Riera
authors.affiliation: 1 Intensive Care Department, Hospital Universitari de Bellvitge , IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge). L'Hospitalet de Llobregat, Barcelona, Spain .
authors.forename: Xose L
authors.initials: XL
authors.lastname: Perez-Fernandez
authors.affiliation: 2 Intensive Care Department, Hospital de la Santa Creu i Sant Pau , Barcelona, Spain .
authors.forename: Antoni J
authors.initials: AJ
authors.lastname: Betbese
authors.affiliation: 2 Intensive Care Department, Hospital de la Santa Creu i Sant Pau , Barcelona, Spain .
authors.forename: Joan A
authors.initials: JA
authors.lastname: Roncal
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D001419:Bacteria / Q000302:isolation & purification; D016638:Critical Illness / Q000453:epidemiology* / Q000401:mortality; D005260:Female; D005658:Fungi / Q000302:isolation & purification; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D010538:Peritonitis / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality; D011446:Prospective Studies; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D000935:Antifungal Agents