Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome.

PURPOSE: Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery. METHODS: Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48 h later. Therein, decision for definite reconstruction (anastomosis or Hartmann's procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed. RESULTS: Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p = 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p = 0.001), and increased operation time (105 vs. 84 min., p = 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p < 0.001). Complication rate (44 vs. 24%, p = 0.092), mortality (12 vs. 0%, p = 0.061), overall number of surgeries (3.4 vs. 2.4, p = 0.017), enterostomy rate (76 vs. 36%, p = 0.001), and length of hospital stay (25 vs. 18.8 days, p = 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p = 0.005) and with fungal infection (100 vs. 49%, p = 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p < 0.001), enterostomy rate (81 vs. 48%, p = 0.017), and anastomotic leakage (29 vs. 6%, p = 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p = 0.014). CONCLUSION: Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.

Prevention of HIV infection in women.

The number of HIV-infected women in the United States has continued to rise. Although risk-reducing behaviors such as condom use, partner selection, partner reduction, and safe sex practices have been identified, women continue to engage in high-risk activities. Nurses need to offer testing for HIV infection to all women. Education programs directed at the transmission and prevention of HIV infection also are needed. This article describes nursing strategies designed to incorporate primary, secondary, and tertiary prevention of HIV infection in women.

PIP: The incidence of HIV infection in US women is rising, with a disproportionate number of cases in racial/ethnic minorities and urban women. This increasing trend will soon place AIDS as one of the top 5 causes of death for women aged 25-44. Horizontal transmission of HIV occurs through the exchange of blood, semen, and vaginal/cervical secretions. High-risk activities for women include sharing needles during iv drug use or engaging in sexual intercourse with a man who shares needles, is bisexual, was born in sub=Sahara Africa or in a Caribbean country, or is HIV infected. Women can prevent HIV infection by condom use, careful partner selection, reducing the number of sexual partners, refusing to share needles, and eliminating risky sexual behavior (such as anal intercourse). Nurses can reduce the spread of HIV infection in women by following 3 strategies. Primary strategies help women increase their level of perceived risk, allow nurses to identify and assess high-risk women through screening, and educate women about the transmission and prevention of HIV. Secondary prevention includes early detection and education to prevent further transmission of the disease. Counseling and partner notification are important aspects of this strategy. Tertiary prevention is early medical and psychiatric intervention to help the women manage and live with the disease. Nursing strategies should incorporate all 3 level of prevention.