Actualización en infecciones intraabdominales. Manejo en terapia intensiva
Barra lateral del artículo
Publicado:
feb 1, 2023
Palabras clave:
infecciones abdominales, candidiasis intrabdominal, peritonitis secundaria, plastrón apendicular, bolsa de Bogotá
Contenido principal del artículo
Resumen
Las infecciones intraabdominales representan una causa importante de morbimortalidad. Su manejo requiere un enfoque multidisciplinario que involucra a médicos intensivistas y equipo quirúrgico. El tratamiento de las infecciones intraabdominales complicadas implica tanto la terapia antimicrobiana como el control quirúrgico del foco. La elección del antimicrobiano debe basarse tanto en la gravedad de la infección como en los factores de riesgo para patógenos resistentes, flora local y en los antecedentes individuales.
Cuando se presentan con sepsis y shock séptico aumenta la mortalidad hasta el 60%. Realizar diagnóstico y tratamiento adecuado y precoz son los pilares fundamentales para mejorar los resultados
Detalles del artículo
Cómo citar
1.
chediack viviana, Dominguez CV, Lamberto Y, Saul PA, Balasini C, Gonzalez AL, et al. Actualización en infecciones intraabdominales. Manejo en terapia intensiva. Rev Arg de Ter Int. [Internet]. 1 de febrero de 2023 [citado 22 de noviembre de 2024];40(enero). Disponible en: https://revista.sati.org.ar/index.php/MI/article/view/838
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Citas
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3.Blot S, Antonelli M, Arvaniti K, Blot K, Creagh Brown B, de Lange D, et al. Epidemiology of intra-abdominal infection and sepsis in critically ill patients: “AbSeS”, a multinational observational cohort study and ESICM Trials Group Project. Intensive Care Med 2019 Dec;45(12): 1703-1717.doi: 10.1007/s00134-019-05819-3.
4.Sartelli M, Coccolini F, Kluger Y, Agastra E, Abu-Zidan F, El Sayed Abbas A. et al. WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections. World J Emerg Surg 2021 Sep 25;16(1):49.
doi: 10.1186/s13017-021-00387-8.
6.Clara L, Rodríguez V, Saúl P, Domínguez C, Esteban M. Infecciones intraabdominales. Puesta al día y recomendaciones de la sociedad argentina de infectología. MEDICINA (Buenos Aires) 2018; 78: 417-426
7.Hotchkiss R, Moldawer L, Opal S, Reinhart K, Turnbull I, Vincent J. Sepsis and septic shock. Nat Rev Dis Primers.2016 Jun 30;2:16045:1-47
doi: 10.1038/nrdp.2016.45
8.Mazuski J, Tessier J, May A, Sawyer R, Nadler E, Rosengart M, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt). 2017 Jan;18(1):1-76. doi: 10.1089/sur.2016.261.
9.Xiuwen W , Ji W , Peige W , Colmillo X , Yunsong Y , Tang J , et al. Diagnosis and Management of Intraabdominal Infection: Guidelines by the Chinese Society of Surgical Infection and Intensive Care and the Chinese College of Gastrointestinal Fistula Surgeons. Clin Infect Dis. 2020 Dec 23;71(Suppl 4): S337-S362. doi: 10.1093/cid/ciaa1513.
10. Pereyra C. Infecciones intraabdominales. En: Editorial Panamericana. Terapia Intensiva 5ta edición. Sociedad Argentina de Terapia Intensiva. 2015.Capitulo IX-6: 844-850
11.Pinto L, Pereira J, Cunha R, Pinto P, Sirlin C. CT evaluation of appendicitis and its complications: imaging techniques and key diagnostic findings. AJR Am J Roentgenol 2005 Aug;185(2):406-17. doi: 10.2214/ajr.185.2.01850406.
12.Duke E, Kalb B, Arif-Tiwari H, Daye ZJ, Gilbertson-Dahdal D, Keim S, et al. A systematic review and meta-analysis of diagnostic performance of MRI for evaluation of acute appendicitis. AJR Am J Roentgenol.2016 Mar;206(3): 508-17. doi: 10.2214/AJR.15.14544.
13. De Waele J. Early source control in sepsis. Langenbecks Arch Surg 2010 Jun;395(5): 489-94.doi: 10.1007/s00423-010-0650-1.
14.Cecconi M, Evans L, Levy M, Rhodes A. Sepsis and septic shock. Lancet. 2018 Jul 7;392(10141): 75-87.doi: 10.1016/S0140-6736(18)30696-2.
15. Sartelli M, Catena F, Abu-Zidan F, Ansaloni L, Biffl W, Boermeester M, et al. Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference. World J Emerg Surg. 2017 May 4; 12: 22.doi: 10.1186/s13017-017-0132-7.
16. Azzarello G, Lanteri R, Rapisarda C, Santangelo M, Racalbuto A, Minutolo V, et al. Ultrasound-guided percutaneous treatment of abdominal collections. Chir Ital. 2009; 61:337–40.
17. Gomi H, Solomkin J, Takada T, Strasberg S, Pitt H, Yoshida M, et al. TG13 antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013 Jan;20(1):60-70. doi: 10.1007/s00534-012-0572-0.
18. Sartelli M, Weber D, Ruppé E, Bassetti M, Wright B, Ansaloni L, et al. Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA). World J Emerg Surg (2016)11: 33.doi:10.1186/s13017-016-0089-y.
19. Sartelli M, Chichom-Mefire A, Labricciosa F, Hardcastle T, Abu-Zidan F, Adesunkanmi A. The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intraabdominal infections. World J Emerg Surg. 2017 Jul 10; 12:29. doi: 10.1186/s13017-017-0141-6.
20.Driscoll T, Crank C. Vancomycin-resistant enterococcal infections: Epidemiology, clinical manifestations, and optimal management. Infect Drug Resist. 2015 Jul 24; 8:217-30. doi: 10.2147/IDR.S54125.
21.Golan Y. Empiric therapy for hospital-acquired, Gram-negative complicated intra-abdominal infection and complicated urinary tract infections: a systematic literature review of current and emerging treatment options. BMC Infect Dis. 2015 Aug 5; 15: 313.doi: 10.1186/s12879-015-1054-1.
22. Perrone G, Sartelli M, Giuffrida M, Chichom-Mefired A, Labricciosa F, Abu-Zidan F, et al. Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations. Int J Infect Dis. 2020 Oct; 99:140-148. doi: 10.1016/j.ijid.2020.07.046.
23. Montori G, Allievi N, Coccolini F, Solaini L, Campanati L, Ceresoli M, et al. Negative Pressure Wound Therapy versus modified Barker Vacuum Pack as temporary abdominal closure technique for Open Abdomen management: a four-year experience. BMC Surg. 2017 Jul 21;17(1):86.
doi: 10.1186/s12893-017-0281-3.
24. Kirkpatrick A, Roberts D, Faris P, Ball Ch, Kubes P, Tiruta C, et al. Active Negative Pressure Peritoneal Therapy After Abbreviated Laparotomy. The Intraperitoneal Vacuum Randomized Controlled Trial. Ann Surg. 2015 Jul;262(1): 38-46.doi: 10.1097/SLA.0000000000001095.
25. Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev. 2005;(3): CD001439.doi: 10.1002/14651858.CD001439.pub2.
26.Sawyer R, Claridge J, Nathens A, Rotstein O, Duane T, Evans H, et al. Trial of short-course Antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015 May 21;372(21): 1996-2005.doi: 10.1056/NEJMoa1411162.
27. Smith S, Rumbaugh K, May A. Evaluation of short course of antimicrobial therapy for complicated intraabdominal infections in critically ill surgical patients. Surg Infect (Larchmt). Aug/Sep 2017;18(6): 742-750.doi: 10.1089/sur.2017.011.
28 Sartelli M, Catena F, Ansaloni L, Coccolini F, Di Saverio S, Griffiths E. Duration of antimicrobial therapy in treating complicated intra-abdominal infections: a comprehensive review. Surg Infect (Larchmt). 2016 Feb;17(1):9-12. doi: 10.1089/sur.2015.130.
29.Guirao X, Arias J, Badía J, García-Rodríguez J, Mensa J, Álvarez-Lerma F, et al. Recommendations in the empiric anti-infective agents of intra-abdominal infection. Rev Esp Quimioter. 2009 Sep;22(3):151-72.
30. Bassetti M, Righi E, Ansaldi F, Merelli M, Scarparo C, Mesini A, et al. A multicenter multinational study of abdominal candidiasis: epidemiology, outcomes and predictors of mortality. Intensive Care Med. 2015 Sep;41(9):1601-10. doi: 10.1007/s00134-015-3866-2.
31.Dupont H, Paugam-Burtz C , Muller- Serieys C , Fierobe L , Chosidow D, Marmuse J, et al. Predictive Factors of Mortality Due to Polymicrobial Peritonitis With Candida Isolation in Peritoneal Fluid in Critically Ill Patients. Arch Surg. 2002.Dec;137(12):13416;discussion1347. doi:10.1001/archsurg.137.12.1341.
32. Zappella N, Desmard M, Chochillon C, Ribeiro-Parenti L, Houze S, Marmuse J, et al. Positive peritoneal fluid fungal cultures in postoperative peritonitis after bariatric surgery. Clin Microbiol Infect. 2015 Sep;21(9): 853.e1-3. doi: 10.1016/j.cmi.2015.05.024.
33.Sandven P, Ovist H, Skoylund E, Giercksky K, NORGAS Group, Norwegian Yeast Study Group. Significance of Candida recovered from intraoperative specimens in patients with intra-abdominal perforations. Crit Care Med. 2002 Mar;30(3): 541-7.doi: 10.1097/00003246-200203000-00008.
34. Úbeda A, Loza Vázquez A, León Gil C. Peritonitis candidiásica. Cándida peritonitis. Enferm Infecc Microbiol Clin.2010;28(Supl2):42-48. doi: 10.1016/S0213-005X(10)70029-X.
35. Bassetti M, Marchetti M, Chakrabarti A, Colizza S, Garnacho-Montero J, Kett H. A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts. Intensive Care Med.2013 Dec;39(12): 2092-106.doi: 10.1007/s00134-013-3109-3.
36. Ostrosky- Zeichner L, Al-Obaidi M .Invasive Fungal Infections in the Intensive Care Unit. Infect Dis Clin North Am. 2017 Sep;31(3):475-487.
doi: 10.1016/j.idc.2017.05.005.
37. Eggimanna P, Ostrosky-Zeichner L. Early antifungal intervention strategies in ICU patients. Curr Opin Crit Care. 2010 Oct;16(5):465-9.
doi: 10.1097/MCC.0b013e32833e0487.
38. Pappas P, Kauffman C, Andes D, Clancy C, Marr K, Ostrosky-Zeichner L, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America.
Clin Infect Dis. 2016 Feb 15;62(4): e1-50.doi: 10.1093/cid/civ933
39.Tschaikowsky K, Hedwig-Geissing M, Schmidt J, Braun G. Lipopolysaccharide-Binding Protein for Monitoring of Postoperative Sepsis: Complemental to C-Reactive Protein or Redundant? PLoS One. 2011;6(8): e23615.doi: 10.1371/journal.pone.0023615.
40. Parlato M, Philippart F, Rouquette A, Moucadel V, Puchois V, Blein S, et al. Captain Study Group Circulating biomarkers may be unable to detect infection at the early phase of sepsis in ICU patients: the CAPTAIN prospective multicenter cohort study. Intensive Care Med. 2018 Jul;44(7):1061-1070.
doi: 10.1007/s00134-018-5228-3.
41. Heyland D, Johnson A, Reynolds S, MuscedereJ. Procalcitonin for reduced antibiotic exposure in the critical care setting: a systematic review and an economic evaluation. Crit Care Med. 2011 Jul;39(7):1792-9.
doi: 10.1097/CCM.0b013e31821201a5.
42.Jong E, van Oers J, Beishuizen A, Vos P, Vermeijden W, Haas L, et al. Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial. Lancet Infect Dis. Lancet Infect Dis. 2016 Jul;16(7):819-827.
doi: 10.1016/S1473-3099(16)00053-0 2016; (16):819–827.
2.Montravers P, Blot S, Dimopoulos G, Eckmann C, Eggimann P, Guirao X, et al. Therapeutic management of peritonitis: a comprehensive guide for intensivists. Intensive Care Med. 2016 Aug;42(8):1234-47. doi: 10.1007/s00134-016-4307-6.
3.Blot S, Antonelli M, Arvaniti K, Blot K, Creagh Brown B, de Lange D, et al. Epidemiology of intra-abdominal infection and sepsis in critically ill patients: “AbSeS”, a multinational observational cohort study and ESICM Trials Group Project. Intensive Care Med 2019 Dec;45(12): 1703-1717.doi: 10.1007/s00134-019-05819-3.
4.Sartelli M, Coccolini F, Kluger Y, Agastra E, Abu-Zidan F, El Sayed Abbas A. et al. WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections. World J Emerg Surg 2021 Sep 25;16(1):49.
doi: 10.1186/s13017-021-00387-8.
6.Clara L, Rodríguez V, Saúl P, Domínguez C, Esteban M. Infecciones intraabdominales. Puesta al día y recomendaciones de la sociedad argentina de infectología. MEDICINA (Buenos Aires) 2018; 78: 417-426
7.Hotchkiss R, Moldawer L, Opal S, Reinhart K, Turnbull I, Vincent J. Sepsis and septic shock. Nat Rev Dis Primers.2016 Jun 30;2:16045:1-47
doi: 10.1038/nrdp.2016.45
8.Mazuski J, Tessier J, May A, Sawyer R, Nadler E, Rosengart M, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt). 2017 Jan;18(1):1-76. doi: 10.1089/sur.2016.261.
9.Xiuwen W , Ji W , Peige W , Colmillo X , Yunsong Y , Tang J , et al. Diagnosis and Management of Intraabdominal Infection: Guidelines by the Chinese Society of Surgical Infection and Intensive Care and the Chinese College of Gastrointestinal Fistula Surgeons. Clin Infect Dis. 2020 Dec 23;71(Suppl 4): S337-S362. doi: 10.1093/cid/ciaa1513.
10. Pereyra C. Infecciones intraabdominales. En: Editorial Panamericana. Terapia Intensiva 5ta edición. Sociedad Argentina de Terapia Intensiva. 2015.Capitulo IX-6: 844-850
11.Pinto L, Pereira J, Cunha R, Pinto P, Sirlin C. CT evaluation of appendicitis and its complications: imaging techniques and key diagnostic findings. AJR Am J Roentgenol 2005 Aug;185(2):406-17. doi: 10.2214/ajr.185.2.01850406.
12.Duke E, Kalb B, Arif-Tiwari H, Daye ZJ, Gilbertson-Dahdal D, Keim S, et al. A systematic review and meta-analysis of diagnostic performance of MRI for evaluation of acute appendicitis. AJR Am J Roentgenol.2016 Mar;206(3): 508-17. doi: 10.2214/AJR.15.14544.
13. De Waele J. Early source control in sepsis. Langenbecks Arch Surg 2010 Jun;395(5): 489-94.doi: 10.1007/s00423-010-0650-1.
14.Cecconi M, Evans L, Levy M, Rhodes A. Sepsis and septic shock. Lancet. 2018 Jul 7;392(10141): 75-87.doi: 10.1016/S0140-6736(18)30696-2.
15. Sartelli M, Catena F, Abu-Zidan F, Ansaloni L, Biffl W, Boermeester M, et al. Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference. World J Emerg Surg. 2017 May 4; 12: 22.doi: 10.1186/s13017-017-0132-7.
16. Azzarello G, Lanteri R, Rapisarda C, Santangelo M, Racalbuto A, Minutolo V, et al. Ultrasound-guided percutaneous treatment of abdominal collections. Chir Ital. 2009; 61:337–40.
17. Gomi H, Solomkin J, Takada T, Strasberg S, Pitt H, Yoshida M, et al. TG13 antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013 Jan;20(1):60-70. doi: 10.1007/s00534-012-0572-0.
18. Sartelli M, Weber D, Ruppé E, Bassetti M, Wright B, Ansaloni L, et al. Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA). World J Emerg Surg (2016)11: 33.doi:10.1186/s13017-016-0089-y.
19. Sartelli M, Chichom-Mefire A, Labricciosa F, Hardcastle T, Abu-Zidan F, Adesunkanmi A. The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intraabdominal infections. World J Emerg Surg. 2017 Jul 10; 12:29. doi: 10.1186/s13017-017-0141-6.
20.Driscoll T, Crank C. Vancomycin-resistant enterococcal infections: Epidemiology, clinical manifestations, and optimal management. Infect Drug Resist. 2015 Jul 24; 8:217-30. doi: 10.2147/IDR.S54125.
21.Golan Y. Empiric therapy for hospital-acquired, Gram-negative complicated intra-abdominal infection and complicated urinary tract infections: a systematic literature review of current and emerging treatment options. BMC Infect Dis. 2015 Aug 5; 15: 313.doi: 10.1186/s12879-015-1054-1.
22. Perrone G, Sartelli M, Giuffrida M, Chichom-Mefired A, Labricciosa F, Abu-Zidan F, et al. Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations. Int J Infect Dis. 2020 Oct; 99:140-148. doi: 10.1016/j.ijid.2020.07.046.
23. Montori G, Allievi N, Coccolini F, Solaini L, Campanati L, Ceresoli M, et al. Negative Pressure Wound Therapy versus modified Barker Vacuum Pack as temporary abdominal closure technique for Open Abdomen management: a four-year experience. BMC Surg. 2017 Jul 21;17(1):86.
doi: 10.1186/s12893-017-0281-3.
24. Kirkpatrick A, Roberts D, Faris P, Ball Ch, Kubes P, Tiruta C, et al. Active Negative Pressure Peritoneal Therapy After Abbreviated Laparotomy. The Intraperitoneal Vacuum Randomized Controlled Trial. Ann Surg. 2015 Jul;262(1): 38-46.doi: 10.1097/SLA.0000000000001095.
25. Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev. 2005;(3): CD001439.doi: 10.1002/14651858.CD001439.pub2.
26.Sawyer R, Claridge J, Nathens A, Rotstein O, Duane T, Evans H, et al. Trial of short-course Antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015 May 21;372(21): 1996-2005.doi: 10.1056/NEJMoa1411162.
27. Smith S, Rumbaugh K, May A. Evaluation of short course of antimicrobial therapy for complicated intraabdominal infections in critically ill surgical patients. Surg Infect (Larchmt). Aug/Sep 2017;18(6): 742-750.doi: 10.1089/sur.2017.011.
28 Sartelli M, Catena F, Ansaloni L, Coccolini F, Di Saverio S, Griffiths E. Duration of antimicrobial therapy in treating complicated intra-abdominal infections: a comprehensive review. Surg Infect (Larchmt). 2016 Feb;17(1):9-12. doi: 10.1089/sur.2015.130.
29.Guirao X, Arias J, Badía J, García-Rodríguez J, Mensa J, Álvarez-Lerma F, et al. Recommendations in the empiric anti-infective agents of intra-abdominal infection. Rev Esp Quimioter. 2009 Sep;22(3):151-72.
30. Bassetti M, Righi E, Ansaldi F, Merelli M, Scarparo C, Mesini A, et al. A multicenter multinational study of abdominal candidiasis: epidemiology, outcomes and predictors of mortality. Intensive Care Med. 2015 Sep;41(9):1601-10. doi: 10.1007/s00134-015-3866-2.
31.Dupont H, Paugam-Burtz C , Muller- Serieys C , Fierobe L , Chosidow D, Marmuse J, et al. Predictive Factors of Mortality Due to Polymicrobial Peritonitis With Candida Isolation in Peritoneal Fluid in Critically Ill Patients. Arch Surg. 2002.Dec;137(12):13416;discussion1347. doi:10.1001/archsurg.137.12.1341.
32. Zappella N, Desmard M, Chochillon C, Ribeiro-Parenti L, Houze S, Marmuse J, et al. Positive peritoneal fluid fungal cultures in postoperative peritonitis after bariatric surgery. Clin Microbiol Infect. 2015 Sep;21(9): 853.e1-3. doi: 10.1016/j.cmi.2015.05.024.
33.Sandven P, Ovist H, Skoylund E, Giercksky K, NORGAS Group, Norwegian Yeast Study Group. Significance of Candida recovered from intraoperative specimens in patients with intra-abdominal perforations. Crit Care Med. 2002 Mar;30(3): 541-7.doi: 10.1097/00003246-200203000-00008.
34. Úbeda A, Loza Vázquez A, León Gil C. Peritonitis candidiásica. Cándida peritonitis. Enferm Infecc Microbiol Clin.2010;28(Supl2):42-48. doi: 10.1016/S0213-005X(10)70029-X.
35. Bassetti M, Marchetti M, Chakrabarti A, Colizza S, Garnacho-Montero J, Kett H. A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts. Intensive Care Med.2013 Dec;39(12): 2092-106.doi: 10.1007/s00134-013-3109-3.
36. Ostrosky- Zeichner L, Al-Obaidi M .Invasive Fungal Infections in the Intensive Care Unit. Infect Dis Clin North Am. 2017 Sep;31(3):475-487.
doi: 10.1016/j.idc.2017.05.005.
37. Eggimanna P, Ostrosky-Zeichner L. Early antifungal intervention strategies in ICU patients. Curr Opin Crit Care. 2010 Oct;16(5):465-9.
doi: 10.1097/MCC.0b013e32833e0487.
38. Pappas P, Kauffman C, Andes D, Clancy C, Marr K, Ostrosky-Zeichner L, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America.
Clin Infect Dis. 2016 Feb 15;62(4): e1-50.doi: 10.1093/cid/civ933
39.Tschaikowsky K, Hedwig-Geissing M, Schmidt J, Braun G. Lipopolysaccharide-Binding Protein for Monitoring of Postoperative Sepsis: Complemental to C-Reactive Protein or Redundant? PLoS One. 2011;6(8): e23615.doi: 10.1371/journal.pone.0023615.
40. Parlato M, Philippart F, Rouquette A, Moucadel V, Puchois V, Blein S, et al. Captain Study Group Circulating biomarkers may be unable to detect infection at the early phase of sepsis in ICU patients: the CAPTAIN prospective multicenter cohort study. Intensive Care Med. 2018 Jul;44(7):1061-1070.
doi: 10.1007/s00134-018-5228-3.
41. Heyland D, Johnson A, Reynolds S, MuscedereJ. Procalcitonin for reduced antibiotic exposure in the critical care setting: a systematic review and an economic evaluation. Crit Care Med. 2011 Jul;39(7):1792-9.
doi: 10.1097/CCM.0b013e31821201a5.
42.Jong E, van Oers J, Beishuizen A, Vos P, Vermeijden W, Haas L, et al. Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial. Lancet Infect Dis. Lancet Infect Dis. 2016 Jul;16(7):819-827.
doi: 10.1016/S1473-3099(16)00053-0 2016; (16):819–827.