Gastric Perforation in Temporary Abdominal Closure as a Predictor of Fungal Intra-abdominal Infection in Trauma Patients

Author(s):
Leonardo Diaz; Alejandro De Filippis; Melissa Canas; Ricardo Fonseca; Hussain Afzal; Jennifer Leonard; Mark Hoofnagle; Kelly Bochicchio; Grant Bochicchio

Background:

Gastric perforation has been linked to intra-abdominal Candida infections. The use of temporary abdominal closure (TAC) has also been shown to increase the rate of fungal intra-abdominal infection (FIAI). We analyzed the association between gastric injuries in trauma patients who underwent TAC and their risk of FIAI.

Hypothesis:

We hypothesized that patients with gastric perforations in the setting of TAC have a higher incidence of FIAI than bacterial intra-abdominal infection (BIAI).

Methods:

Our prospectively maintained Trauma Registry was queried for all level 1 trauma patients who underwent an emergency laparotomy and TAC between August 2019 and August 2022.  Patients were stratified by FIAI vs BIAI. Demographics, intra-operative findings, culture data, antimicrobials, and clinical outcomes were collected. The diagnosis of FIAI and BIAI was confirmed by Infection Disease consultation. Data were analyzed using Student’s t-test, Chi^–square, and multi-variable logistic regression.

Results:

1,030 level one trauma patients were admitted during the study period. Of these, 87 patients required emergency laparotomy with TAC. Most patients were male (85.1%) and admitted for penetrating trauma (71.3%). There were a total of 14 intra-abdominal infections (16.1%) with an equal number of FIAIs (n= 7) and BIAIs (n=7). Five of the 7 patients with FIAI (71.4%) had gastric perforation as compared to 14.3% in the BIAI group (p=0.045). There were no statistically significant differences in demographics or comorbidities. The FIAI group had a significantly higher rate of ICU readmission (42.8% vs 14.3% p 0.024) compared to the BIAI group.  When analyzed by multivariable logistic regression in patients with TAC, controlling for gastric injuries vs non-gastric injuries; BMI, mechanisms of injury, number of laparotomies, APACHE and IV drug use, the combination of gastric injuries and TAC was found to have 17-fold increase in FIAI (OR 17.042, P 0.018).

Conclusions:

Gastric perforation in the setting of TAC is more predictive of FIAI than BIAI in critically injured trauma patients. FIAI patients also had a significantly higher rate of ICU readmission. Surgeons should be aware of the high rate of FIAI in this high-risk patient population and consider early empiric antifungal treatment.