There were few studies that assessed the relationship between antibiotic therapy and prognosis in severe abdominal infection patients whatever the infection sources were controlled or not to evaluate the appropriate antibiotic therapy. We retrospectively investigated patients' characteristics, culture results, antibiotic therapy and prognosis with medical records of 86 abdominal infection patients admitted in our ICU from April 2013 to March 2016. In an univariate analysis, increased 28-day mortality was associated with multi-antibiotic administration at the first, increased total duration of antibiotic therapy, and high rate detection of antibiotic-resistant bacteria, and multi-antibiotic administration at the first and detection of antibiotic-resistant bacteria also remained in the multivariate analysis. Further studies of larger sample size are needed to evaluate the effect of multi-drug use and the type of drug resistance.

This study investigated the influence of preoperative chemotherapy on postoperative infectious complication (PIC) after hepatic resection for colorectal liver metastases. One hundred and fifty two patients who underwent hepatic resection without synchronous primary tumor resection between April 2011 and December 2015 were classified into two groups according to the presence (PC group: n=105)or absence (NPC group: n=47)of preoperative chemotherapy. Perioperative outcomes in the two groups were retrospectively compared. More patients of PC group suffered from preoperative hypoalbuminemia and severe surgical stress, estimated by the extent of liver resection, operative time and blood loss, compared to those of NPC group. The incidence of PIC was significantly higher in patients of PC group than in those of NPC group (32% vs. 15%, P<0.05). Multivariate analysis revealed that diabetes mellitus, sinusoidal obstruction syndrome grade of nontumor-bearing liver, biliary fistula and preoperative chemotherapy were associated with the development of PICs. The increased risk of PICs was observed particularly among patients who had received 16 weeks or longer duration of chemotherapy. These results suggest that shorter duration chemotherapy is preferable in terms of risk reduction for PIC, and careful postoperative management is needed especially for those exposed to prolonged chemotherapy.

【Purpose】The rate of surgical site infection (SSI) is about 80 percent in case of perforative peritonitis. There is reported that negative pressure wound therapy (NPWT) was effective for the postoperative wound of perforative peritonitis. We retrospectively evaluated the effect of NPWT in preventing complications of the postoperative wound of perforative peritonitis. 【Methods】Fifty nine patients were treated with primary closure between January 2010 and December 2014(C group), and 42 patients were treated with NPWT between January 2015 and August 2016 (N group). Rates of SSIs were retrospectively compared between C group and N group. 【Results】The rate of SSI was lower in the N group (45.8% VS 9.5%, P<0.001). Postoperative hospital days was lower in the N group (35days VS 24days, P=0.003). 【Conclusion】Prophylactic NPWT is useful to decrease the rate of SSIs after the operation of per-forative peritonitis and the postoperative hospital days.

To promote appropriate use of antimicrobials, our antimicrobial stewardship (AMS) including the interim report of culture results or detected resistant bacteria to physicians, which made by pharmacist and clinical laboratory technician, was started in 2013. We conducted 5-year retrospective study of outcome measurement after implementation of AMS. We found that maximum decreased of total use (AUD) and days of therapy (DOT)were −28% ( P<0.01), -29% (P<0.01), without increasing of length of stay (LOS) and mortality. The maximum significant increase of the susceptibility of piperacillin/tazobactam (from 89 to 100%, P<0.05), imipenem/cilastatin (from 70 to 95%, P＜0.01)meropenem(from 75 to 100%, P<0.01), ciprofloxacin(from 79 to 97%, P<0.01) to Pseudomonas aeruginosa (PA, were significant found, whereas there was no significant correlation between the AUD of anti-pseudomonas agent and the susceptibility to PA. The percentage of 3-hour infusion cases of meropenem in surgical wards was 92.1%, and higher than that of non-surgical wards. We suggest that this report system contribute to diagnosis of infectious disease and streamlining of antimicrobial therapy. Also higher percentage of 3-hour infusion cases of meropenem might led to improving susceptibility of PA.

The blood culture test (BCT) is one of the most important laboratory examinations for exploring of infectious disease. In our institute, this test did not perform appropriately, especially in surgical departments. One year from April 2014, we perform a campaign for appropriate BCT. We advertised for BCT in patients with any infectious diseases before antimicrobial drug administration and multiple sets BCT. Before the campaign, rate of multiple sets BCT in whole hospital, rate of multiple sets BCT in surgical departments and number of BCT were 18.2％, 12.1％ and 182 patients, respectively. After one year of campaign, these dates were 67.0％, 75.4％ and 252 patients, respectively. After the campaign year, we continued to approach the doctors to perform the appropriate BCT. The rates of multiple set BCT in whole hospital from 2015 to 2017 were 86.0％, 89.1％ and 91.0％, respectively. To perform the campaign of appropriate BCT in whole hospital, the rate of multiple sets BCT was improved both whole hospital and surgical departments. The campaign of appropriate BCT has to perform continuously for improvement of accuracy of BCT.

One of the goal of Japan Society for Surgical Infection is enlightenment of appropriate perioperative management for prevention of surgical site infections. The board of education of the society conducted a joint symposium with Japanese Society for Infection Prevention and Control since 2016. Current practices of perioperative management was investigated in February, 2017 at the annual meeting of Japanese Society for Infection Prevention and Control. Two hundred participants were included using analyzer. Regarding a question of preoperative bowel preparation for colorectal surgery, seventy two percent of attendance answered only mechanical preparation without preoperative oral antibiotics.

Surgical site infection is the second most common cause of healthcare-associated infections. It is important task to diminish the surgical infections including SSI. Because surgeons often use broad-spectrum antibiotics for longer period than recommended period in the treatment of healthcare-associated infections, antimicrobial stewardship is also necessary to surgeons. This article summarizes the knowledge of education on surgical infection control.

One of the main roles of ICD is “education and awareness of medical staff”. It is important for education on infection control to be widely targeted for multiple occupations. So, cooperation and effectiveness in the hospital are essential. For this reason, in addition to its role as a leader, the ICD is also required to act as a coordinator in cooperation within the facility. In this way, it is essential that ICD always play a central role in infection control, so it is desirable to aggressively address education with enthusiasm.

Bile leaks occurring after hepatectomy most seriously compromise patients’quality of life immediately after operation and contribute to increasing healthcare costs. The incidence of bile leaks has been reported to range from 4％ to 12.8％. In patients who undergo hepatocholangiojejunostomy, the incidence increases. We studied the incidences of bile leaks and intra-abdominal abscess among 530 patients who underwent simple hepatectomy or hepatectomy with biliary tract reconstruction. Among the patients who underwent simple hepatectomy, 20 patients （4.3％）had bile leaks, and 5 patients （1.1％）had intra-abdominal abscess. Among the patients who underwent biliary tract reconstruction, 13 patients （21.7％）had bile leaks, and 2 patients （3.3％）had intra-abdominal abscess. Many patients who underwent biliary tract reconstruction had bile leaks, but the incidence of intra-abdominal abscess can apparently be decreased by applying closed suction drainage. Intraperitoneal drainage cultures were positive in 100％ of the patients who underwent biliary tract reconstruction. The causative organisms included enterococci, Pseudomonas aeruginosa, Klebsiella species, and Enterobacter species, which may have been derived from the intestinal tract. The incidence of bile leaks is high in patients who undergo hepatectomy with biliary tract reconstruction, and it is important to prevent intra-abdominal abscess by performing drainage and taking other precautions.

Postpancreatectomy hemorrhage （PPH）is severe complication associated with pancreatic fistula. To prevent intra ─abdominal hemorrhage from the gastroduodenal artery （GDA）stump, falciform ligament wrap around the artery is effective. We performed GDA wrapping with ligation of the artery for four years （n＝143） , and next four years, we wrapped the clipped GDA stump with falciform ligament （n＝202） . The rate of PPH around the hepatic arterial region is 3.5% in Wrapped cases, and 2.5% in Clip & Wrap cases. Delayed hemorrhage of GDA stump is 1.4%, 1.5% in Wrapped cases and Clip & Wrap cases. The incidence of hemorrhage is low in both groups. Wrapped artery is completely separated from abdominal abscess and fatal hemorrhage. Furthermore, wrapped GDA stump is stabilized by arterial clipping, this method is simple and effective procedure to protect the patient from falling into critical condition.

We reviewed past articles of management of biliary leakage after adult living donor liver transplantation (LDLT) and examined outcomes of patients who developed biliary leakage in our center. The incidence of biliary leakage was reported as 2 to 25%. Rapid drainage for abscess or bile duct is required for patients under immunosuppression. In our center, LDLT was performed for 161 adult patients from 1997 to 2017. Twenty patients (12%) were identified to develop biliary leakage. Gram positive coccus such as Enterococcus faecium, Enterococcus faecalis, and Enterobacter cloacae and gram negative bacillus such as Pseudomonas aeruginosa were frequently detected in the bile culture. Out of the 20 cases, 2 died from sepsis and 18 survived employing an appropriate drainage and antibiotic therapy. It is important to understand an appropriate management of biliary leakage for the success of LDLT.

Bile leakage is a frequent, disturbing complication after hepatic resection：its incidence has not changed in 20 years. Bile leakage sometimes becomes intractable, which is strongly associated with space/organ infection. The exposure of the Glissonean sheath, a wide cut surface, and complex procedures are major risk factors for postoperative bile leakage. Leakage sometimes occurs at ≥2 weeks after hepatic resection；the use of a VIO soft-coagulation system near the hepatic hilum or the Glissonean sheath is a suggested risk factor. Bile leakage tests and transcystic duct tube drainage are effective for preventing postoperative bile leakage communicating with the common bile duct (CBD). An abdominal drain should be used for high-risk patients；however, it should be removed during the early postoperative period in cases without bile leakage or space/organ infection. For intractable bile leakage, complete bile drainage and the prevention of space/organ infection are essential. Fistulography or cholangiography should be used to determine whether the leak communicates with the CBD. In some cases biliary decompression such as endoscopic nasobiliary drainage are effective for bile leakage communicating with the CBD, while the injection of fibrin glue or ethanol are sometimes effective for bile leakage that does not communicate with the CBD.

Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgery, such as pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) . In order to evaluate the operative procedures or techniques to prevent POPF after PD or DP, we summarized some randomized controlled trials (RCTs) and meta-analyses of them. Regarding reconstructive procedures in PD, pancreaticogastrostomy was reported safer than pan-creaticojejunostomy. In addition, it was found that pancreatic duct stents tended to reduce POPF after PD compared to non-stent, and there was no significant difference between internal and external stents about the incidence of POPF. In DP, the surgical techniques to transect pancreatic parenchyma are particularly important to prevent POPF. Staple closure has been widely used method in DP, but there were not sufficient evidences that it reduced the rate of POPF compared to other procedures. The reinforcement of pancreatic remnant with mesh was associated with a significant reduced the rate of clinically relevant POPF. In conclusion, the consensus on the best way to prevent POPF after PD or DP remains controversial, so we expect that the further trials will find out them in future.

Postoperative pancreatic fistula in pancreaticoduodenectomy is the clinically most crucial complication which directly relates to surgical mortality despite the development of various surgical techniques and the progress of perioperative management. At present, there is not enough evidence on standard treatment when developing clinical pancreatic fistulas. To establish the safety of pancreaticoduodenectomy, identification of high-risk groups by Fistula Risk Score etc., further improvement of surgical procedures, and standardization of postoperative management for clinical pancreatic fistulas are considered as future tasks.

69-year-old man complained of fever, visual disturbance in the left eye, and cold symptom. The laboratory data showed: hite blood cell count 12,200/μL, platelet count 39,000/μL, C-reactive protein 21.4mg/dL, and was diagnosed with disseminated intravascular coagulation (DIC) . Computed tomography showed an 8cm multiloculated abscess in the segment 8 of the liver and pneumonia, and ophthalmic examination revealed the left endophthalmitis. Blood and sputum culture grew K. pneumoniae. Despite of the administration of antibiotics, fever, leukocytosis, and high level of C-reactive protein lasted. Endophthalmitis and pneumoniae worsened and we found new lung abscesses. On the 9th hospital day, percutaneous drainage for the liver was performed, but the effect was insufficient because of the septum and viscosity. Computed tomography showed thrombophlebitis of the hepatic veins, and we thought it caused hematogenous dissemination. On the 12th hospital day, we performed resection of the segment 8 of the liver. After the operation fever disappeared, white blood cell count and C-reactive protein decreased, and pneumonia improved. We thought this is a case hepatectomy controlled the hematogenous dissemination from liver abscess and thrombophlebitis. Histopathologically, 12mm nodule was confirmed at the proximal side of the abscess and diagnosed as cholangiocarcinoma.

Abstract：A 59-year-old male was transferred to our institution for the treatment of refractory heart failure accompanied by severe systemic inflammation, who had been diagnosed renal impairment due to Henoch-Schönlein purpura 5 months before. Echocardiography revealed severe aortic regurgitation and moderate-severe mitral regurgitation caused by infective endocarditis. His refractory heart failure progressively deteriorated renal function, and thus, urgent aortic and mitral valve replacements were performed using 25mm and 29mm of mechanical prostheses, respectively. Causative organism was not determined during the whole clinical course, and it was decided not to use gentamicin sulfate in consideration of progressive renal dysfunction. His renal histological findings had been characteristic of proliferative glomerulonephritis with granular mesangial immunoglobulin-A deposition, and thus, polyethyleneglycol-treated human immunoglobulin containing the lowest level of Immunoglobulin-A was used in combination with intravenous ampicillin/sulbactam for the initial postoperative anti-inflammatory empiric treatment. Refractory systemic inflammation was immediately ameliorated without irreversible renal dysfunction, and the patient was discharged on the 33rd postoperative day. No signs of recurrent endocarditis were observed during 7 years of follow-up.