The patients in the on-demand relaparotomy group did not have a significantly lower rate of death or major peritonitis-related

morbidity compared with the planned relaparotomy group but did have a substantial reduction in relaparotomies, health care selleck compound utilization, and medical costs. In 2007 a randomised study by Robledo et al. [99] compared open with closed “”on demand”" management of severe peritonitis. The study however was interrupted after the inclusion of 40 patients because of a high rate of mortality for the open abdomen group (55 vs 30%). The “”open abdomen”" was managed with only a non-absorbable polypropylene mesh. Antimicrobial therapy in Intra-abdominal Infections Antimicrobial therapy plays an integral role in the management of intra-abdominal infections. The choice of an inadequate antimicrobial agent is a cause of therapeutic failure. Complicated intra-abdominal infections are predominantly related

to bowel perforation and contamination with its flora. The microbial etiology depends on the level of disruption of the gastrointestinal tract. Microbiology The upper gastrointestinal tract (stomach, duodenum, jejunum, and upper ileum) contains relatively few microselleck organisms, less than 103 to 105 bacteria/mL. Infections derived from the stomach, duodenum, and proximal small bowel can be caused by gram-positive and gram-negative aerobic and facultative organisms. The lower Fosbretabulin price gastrointestinal tract contains hundreds of bacterial species, and concentrations of 1011-13 bacteria/mL. Infections derived from distal ileum perforations can be caused by gram-negative facultative and aerobic organisms with variable density. Colon-derived intra-abdominal infections can be caused by facultative and obligate anaerobic organisms, gram-negative new facultative organism

(Enterobacteriaceae with E. coli at the first place), other gram-negative bacilli and Enterococci. Anaerobic bacteria are 1000 times more common than aerobes. With the exception of Bacteroides spp., most other anaerobes are the main barrier against colonization and infection by other pathogens. The medical antecedents of the patient can affect the normal flora. In particular, patients hospitalised may be colonized by altered flora including multidrug-resistant nosocomial pathogens or Candida spp. Microbiological specimens Once the diagnosis of complicated intra-abdominal infection is suspected, it is appropriate to begin empiric antimicrobial therapy before an exact diagnosis is established and before results of appropriate cultures are available. The role of microbiologic workup of infected fluid has been debated in the last years. Since the causative pathogens can easily be predicted in community acquired infections, bacteriological diagnosis is not necessary.