In the van Ruler trial a total of 232 patients with severe intra-abdominal infections (116 on-demand and 116 planned) were randomized. In planned relaparotomy group, relaparotomies were performed

every 36 to 48 hours after the index laparotomy to inspect, drain, lavage, and perform other necessary abdominal interventions for residual peritonitis or new infectious focus. In on-Demand relaparotomy group, relaparotomies were only performed in patients with clinical deterioration or lack of clinical improvement with a likely intra-abdominal cause. Patients in the on-demand relaparotomy group did not have a significantly lower rate of adverse outcomes compared with patients in the Akt phosphorylation planned relaparotomy group learn more but did have a substantial reduction in relaparotomies, health care utilization, and medical costs. Patients in the on-demand group had shorter median intensive care unit stays (7 vs 11 days; P =.001) and shorter median hospital stays (27 vs 35 days; P =.008). Direct medical costs per patient were reduced by 23% using the on-demand strategy. Some studies have investigated open abdomen in intra-abdominal infections and generated great interest and hope [268–270]. In 2007 a randomized study by Robledo and coll. [271] compared open with closed “”on demand”" management of severe peritonitis. During a 24-month period, 40 patients with SSP were admitted for treatment. Although the difference

in the mortality rate (55% vs. 30%) did not reach statistical significance (p < 0.05; chi-square and Fisher exact test), the

relative risk and odds ratio for death were 1.83 and 2.85 times 17-DMAG (Alvespimycin) HCl higher in open abdomen patients group. This clinical finding, as evidenced by the clear tendency toward a more favorable outcome for patients in closed open group, led to termination of the study at the first interim analysis. This randomized study from a single institution demonstrates that closed management of the abdomen may be a more rational approach after operative treatment of SSP and questions the recent enthusiasm for the open alternative, which has been based on observational studies. However in this study, the “”open abdomen”" was managed with a non-absorbable polypropylene mesh, without topical negative pressure. Antimicrobial treatment of hospital-acquired intra-abdominal infections Hospital-acquired IAIs are among the most difficult infections to diagnose early and treat effectively. A successful outcome depends on early diagnosis, rapid and appropriate surgical intervention, and the selection of effective antimicrobial regimens. Hospital acquired infections are commonly caused by larger and more resistant flora, and for these infections, complex multidrug regimens are always recommended (Recommendation 1 B). The threat of antimicrobial resistance has been identified as one of the major challenges in the management of complicated IAIs and was already discussed in the previous chapter.