Time to Percutaneous Drain Placement and Impact on Patient Outcomes

Abstract

Background:

Percutaneous drains are a commonly used method of source control for intra-abdominal infections. Increased time to source control has been shown to predict worse outcomes in patients with intra-abdominal infections, but it is unclear whether this relationship is valid when the source control method is percutaneous drainage.

Hypothesis:

We hypothesized that increased time from diagnostic imaging to drain placement would be associated with higher complication rates in a population of patients requiring percutaneous drainage for intra-abdominal, retroperitoneal, or pelvic infectious processes.

Methods:

We identified all adult patients who received a percutaneous drain placed by interventional radiology that had positive microbial drain culture results in the abdomen, retroperitoneum, or pelvis from 2020 to 2021 at the University of Kansas Medical Center. Demographics, comorbidities, and Sequential Organ Failure Assessment (SOFA) scores were collected. Multiple organ failure was defined as derangement of two or more organ systems with an SOFA ≥ 3. Standard univariate and logistic regression analyses were performed.

Results:

One hundred seventy patients were included, 94 of whom developed a complication (52%). Drain placement occurred at a median of 20.6 hours (inter-quartile range or IQR: 11.3–31.0 h) overall. Both uni-variable and logistic regression analyses demonstrate that time from imaging read to drain placement did not differ between the complication and non-complication groups.

Conclusion:

In this observational study, the time from diagnosis of intra-abdominal infection to percutaneous drain placement was not associated with increased complication rates even in the sickest patients.

Background

Intra-abdominal infections (IAI) remain a common cause of sepsis worldwide with significant associated morbidity and mortality.^1–3 Sepsis not only contributes to public health costs, but also affects the long-term quality of life for patients.^2–4 Timely source control through a variety of techniques and antimicrobial therapy is the mainstay for the treatment of IAI.^5,6 The definition of “timely” is debatable with both the Surgical Infection Society (SIS) and Surviving Sepsis Campaign recommending source control within 6–12 hours depending on illness severity or as “logistically feasible.”^7,8 In addition, observational studies of the time to source control have yielded mixed results.^9,10

The SIS recommends using the least invasive approach that will achieve source control.^8,11 Yet, percutaneous intervention as the primary method of source control has been understudied in the literature. Similarly, it is unclear if the timing of source control has any bearing on patient outcomes when the method of source control used is percutaneous drainage. The purpose of this study is to examine the timing of percutaneous drainage as the sole method of source control in patients with suspected IAI. We hypothesized that with increased time from diagnostic imaging to percutaneous drain placement there will be higher complication rates in a population of patients requiring interventional radiology (IR) percutaneous drainage for intra-abdominal, retroperitoneal, or pelvic processes.

Methods

This is a single-institution, retrospective, and case-controlled study. We identified all adult patients who received an IR-placed percutaneous drain that had positive microbial culture in the abdomen, retroperitoneum, or pelvis from 2020 to 2021 at our institution. Because our goal was to evaluate intra-abdominal, retroperitoneal, and pelvic abscesses primarily, we excluded peritoneal drains for ascites, biliary decompressions, urinary decompressions, and outpatient procedures. This study was approved by the University of Kansas Medical Center Institutional Review Board (IRB) before study initiation. No ethics approval was required.

Patient demographics, comorbidities, and Sequential Organ Failure Assessment (SOFA) scores were collected. Multiple organ failure (MOF) was defined as derangement of two or more organ systems with an SOFA ≥ 3.¹² The time interval from imaging to drain placement was also recorded.

Complications of percutaneous drainage were stratified and defined as the occurrence of any of the following: in-hospital mortality, subsequent IR drainage procedures, hospital readmission within 30 days of discharge, or a surgical procedure for the same disease process within 30 days of drain placement. Categorical variables were assessed for associations using chi-square tests, and continuous variables were subjected to comparison through the t-test. Multiple logistic regression was performed to assess for association between time to percutaneous drainage and complication.

Results

We identified 170 patients who received an IR-placed percutaneous drain that met our inclusion criteria, with 52.9% experiencing some form of complication (Table 1). The median time from diagnostic imaging to drain placement was 20.6 hours (inter-quartile range [IQR]: 11.3–31.0 h). There was no significant difference in time from diagnostic imaging to drain placement between those who had a complication and those who did not (median 17.0 h vs. 16.1 h; p = 0.88). Complications were not associated with age, Charlson comorbidity index, or rates of a recent abdominal operation. Complications occurred slightly less often in patients with a biliary source for the intra-abdominal infection, but otherwise the source of infection was not associated with complications. Complications did occur more often in patients who met SEPSIS 3 criteria (14 patients, 8.2%) defined as an increase in SOFA score of at least 2 between diagnosis and imaging. MOF defined as an SOFA score of 3 or more was observed in 36 patients (21.2%) and was not associated with complication. Similarly, the time from diagnostic imaging to drain placement was not statistically different between patients who did and did not experience complications (median 17.6 h vs. 23.9 h; p = 0.28).

Table 1.

Demographics, Comorbidities, and Presenting Illness

	Total		(−) Complication		(+) Complication
	n = 170		n = 80		n = 90		p Value
Demographics
Age (years)	60	43–70	61	43–71	59	42–68	0.76
Male sex	104	61.2%	47	58.8%	57	63.3%	0.64
Comorbidities and risk factors
Cigarette smoking	32	18.8%	13	16.3%	19	21.1%	0.44
Abdominal operation in 120 d preceding drain^a	115	67.7%	49	61.3%	66	73.3%	0.10
Charlson comorbidity index	3	1–5	3	1–5	3	1–5	0.53
Immunosuppressed status	25	14.7%	10	12.5%	15	16.7%	0.52
Presenting illness details
Procedure ordered “stat”	58	34.1%	28	35.0%	30	33.3%	0.87
Prior percutaneous drains in place	12	7.0%	6	7.5%	6	6.7%	1.0
Post-organ transplant	9	5.3%	4	5.0%	5	5.6%	1.0
Hospital transfer	22	12.9%	12	15.0%	10	11.1%	0.50
Dx imaging performed in emergency department	78	45.9%	36	45.0%	42	46.7%	0.88
Antibiotic agents received before drain	154	90.6%	72	90.0%	82	91.1%	1.0
Presenting disease etiology per IR consultation note
Abscess	97	57.1%	47	58.8%	50	55.6%	0.76
Hematoma	1	0.6%	1	1.3%	0	0.0%	0.47
Bile leak	1	0.6%	1	1.3%	0	0.0%	0.47
Urinoma	3	1.8%	2	2.5%	1	1.1%	0.60
Pancreatic necrosis	1	0.6%	0	0.0%	1	1.1%	1.0
Peri-transplant fluid collection	4	2.4%	1	1.3%	3	3.3%	0.62
Non-specific fluid collection	46	27.1%	20	25.0%	26	28.9%	0.61
Other	17	10.0%	8	10.0%	9	10.0%	1.0
Anatomical source or location of fluid per Dx imaging
Stomach	0	0.0	—	—	—	—	—
Small intestine	5	2.9%	3	3.8%	2	2.2%	0.67
Large intestine	16	9.4%	7	8.8%	9	10.0%	0.80
Rectum	0	0.0%	—	—	—	—	—
Pancreas	6	3.5%	1	1.3%	5	5.6%	0.22
Biliary system	8	4.7%	7	8.8%	1	1.1%	0.03
Liver	16	9.4%	11	13.%	5	5.6%	0.11
Spleen	1	0.6%	0	0.0%	1	1.1%	1.0
Kidneys	13	7.7%	8	10.0%	5	5.6%	0.39
Bladder or prostate	3	1.8%	0	0.0%	3	3.3%	0.25
Ovaries, fallopian tubes, or uterus	7	4.1%	5	6.3%	2	2.2%	0.26
Unknown or other	95	55.9%	38	47.5%	57	63.3%	0.04
Presenting illness severity scores
SOFA score, 12-h preceding Dx imaging	1	0–2	1	0–2	1	0–2	0.36
SOFA score, 12-h preceding IR drain	1	0–2	1	0–1	1	0–2	0.27
Increase in SOFA score ≥2, Dx imaging to drain	14	8.2%	3	3.8%	11	12.2%	0.05
MOF (two organ systems deranged and SOFA ≥3)	36	21.2%	14	7.5%	22	24.4%	0.35
Admitting service
Acute care or general surgery	29	17.1%	16	20.0%	13	14.4%	0.42
Specialty surgery service	65	38.2%	34	42.5%	37	39.4%	0.34
Internal medicine or family medicine	68	40.0%	26	32.5%	42	46.7%	0.06
Other medical service	8	4.7%	4	5.0%	4	4.4%	1.0

Abdominal, retroperitoneal, or pelvic surgical procedures.

All variables: number (n) and percentage (%) or median and inter-quartile range (IQR).

p Value applies to comparison between cases and controls. Significance p < 0.05.

SOFA, Sequential Organ Failure Assessment; Dx, diagnostic; IR, interventional radiology.

The stratification for complication is shown in Table 2. Fifty-three out of 90 patients (58.9%) were readmitted to the hospital within 30 days. Patients with complications had a longer length of stay. There was no difference in drain timing between patients who did and did not require a subsequent IR drainage procedure (median 20.6 h vs. 21.8 h; p = 0.87), readmission (median 19.0 h vs. 22.2 h; p = 0.19), or a surgical procedure within 30 days (median 20.8 h vs. 22.2 h; p = 0.23). There was no difference in timing between survivors and non-survivors (median 21.6 h vs. 11.6 h; p = 0.23). There was no association between specific pathogens and complication rates following percutaneous drain placement. The most common organisms are listed in Table 3.

Table 2.

Time to Drain Placement and Outcome

	Total		(−) Complication		(+) Complication
	n = 170		n = 80		n = 90		p Value
Time to consult and time to procedure variables
Time from Dx imaging, final read to IR consult (h)	2.1	0.7–9.7	2.8	1.3–14.6	1.6	0.6–5.2	0.02
Time from Dx imaging, final read to drain (h)	20.6	11.3–31.0	22	15.2–30.4	18.5	9.5–31.0	0.13
Time from IR consult to drain (h)	16.0	4.4–23.2	13.0	4.5–23.2	16.5	4.4–24.0	0.61
Time from imaging, final read to drain ≤ 24 h	105	61.8%	46	57.5%	59	65.6%	0.34
IR consult ordered before final imaging read	16	9.4%	5	6.3%	11	12.2%	0.20
Hospital stay details
ICU admission during stay	47	25.5%	20	25.0%	28	31.1%	0.40
Infectious disease consult during stay	96	52.2%	37	46.3%	58	64.4%	0.02
Outcomes
Complication^a	90	52.9%	—	—	90	100%	—
In-hospital mortality^b	9	5.3%	—	—	9	10.0%	—
Subsequent IR percutaneous drain^b	42	24.7%	—	—	42	46.6%	—
Hospital readmission within 30 d^b	53	31.2%	—	—	53	58.9%	—
Operation for same pathology within 30 d of drain^b	27	15.9%	—	—	27	30.0%	—
Hospital length of stay (d)	9	5–19	8	4–13	11	6–20	0.03
Percutaneous drain present at discharge	117	68.8%	60	75.0%	57	63.3%	0.13
Inpatient antibiotic agent duration (d)	5	3–9	5	3–7.5	6	3–13	0.08
Discharged home on antibiotic agents	135	79.4%	68	85.0%	67	74.4%	0.13

Complication defined as present if any of the following occur: in-hospital mortality, subsequent IR percutaneous drain, hospital readmission within 30 days, surgical procedure for same pathology within 30 days of drain.

Outcome defining complication.

All variables: number (n) and percentage (%) or median and inter-quartile range (IQR).

p Value applies to comparison between cases and controls. Significance p < 0.05.

Dx, diagnostic; IR, interventional radiology.

Table 3.

Fluid Culture Results

	Total^a		(−) Complication		(+) Complication
	n = 170		n = 80		n = 90		p Value
Organism
Escherichia coli	65	38.2%	26	32.5%	39	43.3%	0.16
Other spp.	48	28.2%	22	27.5%	26	28.9%	0.86
Enterococcus	46	27.1%	23	28.8%	23	25.6%	0.73
Klebsiella	31	18.2%	16	20.0%	15	16.7%	0.7
Bacteroides spp.	30	17.7%	15	18.8%	15	16.7%	0.84
Candida spp.	30	17.7%	11	13.8%	19	21.1%	0.23
Streptococcus anginosus	20	11.8%	11	13.8%	9	10.0%	0.48
Pseudomonas	13	7.7%	5	6.3%	8	8.9%	0.58
Lactobacillus	9	5.3%	2	2.5%	7	7.8%	0.18
Clostridium, other spp.	8	4.7%	2	2.5%	6	6.7%	0.28

Totals equal greater than 100% as most patients grew multiple organisms.

All data are presented as number (n) and percentage (%).

To determine independent risk factors for complication following IR drain placement, we also performed multiple logistic regression for the total patient population (Table 4). Controlling for age, gender, comorbidity burden, immunosuppression status, and SOFA score, the time from imaging performance to drain placement was not associated with increased complications (OR: 0.99, 95% CI: 0.98–1.01; p = 0.33).

Table 4.

Risk Factors for Complication

Total Population
Variable	OR	95% CI	p Value
Age (years)	0.99	(0.97–1.02)	0.59
Male sex	0.78	(0.41–1.50)	0.44
Charlson comorbidity index	1.03	(0.89–1.20)	0.70
Immunosuppression	1.45	(0.57–3.67)	0.44
Time from Dx imaging, final read to drain (h)	0.99	(0.98–1.01)	0.33
SOFA score, 12 h preceding Dx imaging	1.03	(0.89–1.20)	0.65

Discussion

Intra-abdominal infections amenable to percutaneous drainage are often perceived to be treated less urgently than those requiring operative source control. However, the timing of this intervention has been understudied. Our results demonstrate a median time of 20.6 hours from the final imaging read to percutaneous drainage, with 61.8% of patients getting drainage within 24 hours, falling short of the current SIS recommendations.⁸ Although complications were common in our cohort, time from imaging diagnosis to percutaneous drain placement was not independently associated with complications.

Source control is fundamental for intra-abdominal infection management. Most data suggest that the target time frame for obtaining source control should be within 6–12 h for patients with sepsis or septic shock.^9,13–19 However, guidelines stop short of this specific recommendation for practical reasons instead suggesting that source control be accomplished as soon as logistically feasible and ideally within 24 hours.^7,11 The 2017 SIS guidelines suggested that higher risk patients with sepsis or septic shock should undergo more rapid source control measures, but no specific time frame was recommended.¹¹ The 2024 guidelines have updated that recommendation to within 12 hours for “lower risk” patients and within 6 hours for “higher risk” patients and those with septic shock.⁸ Our study found that, in general, patients were treated outside of the SIS recommendations. Resource limitations are a common reason for “delayed” percutaneous intervention, although perceptions that these patients may be less “sick” than those requiring operative source control may also contribute longer times to percutaneous drainage. A large retrospective analysis of the MEDUSA trial found worse outcomes for patients requiring surgical source control after 6 hours.²⁰ We assume that “surgical” source control did not include percutaneous intervention in their study. We identified no association between the timing of percutaneous drainage and complications. Importantly, our study population had an overall low severity of illness as evidenced by the low SOFA scores and low rates of multi-organ failure, making comparisons with other studies difficult. An observational study by Kim et al also found no significant association between the time from diagnosis to the time of initiation of intervention and overall mortality.¹⁰

There are many indications where adequate source control requires surgical intervention. However, when a less invasive approach utilizing percutaneous drainage is possible for achieving source control for localized intra-abdominal abscesses, this approach is preferred.^21,22 The SIS recommends using the least invasive method available to achieve source control.^8,11 Percutaneous intervention was considered an appropriate method of source control in the STOP-IT trial and these patients did not require longer treatment.^23,24 It is worth noting, however, that percutaneous drainage is far from a benign procedure. Complications (as we have defined them) were extremely common in our study occurring in over 50% of patients and the median length of stay was long (median 9 d). In addition, most patients (79.4%) were discharged home on antibiotic agents. Unfortunately, we do not have data on the duration of post-discharge antibiotic agents. Despite these findings, overall, we support the continued use of percutaneous drainage in appropriate patient populations as the least invasive method of source control.

It is possible that outcomes such as mortality or complication are not ideal for evaluating the impact of this intervention. Since our overall illness severity was low, it may be more difficult to demonstrate difference in these outcomes on the basis of timing of the percutaneous drainage. It is possible that alternative study designs focused on different outcomes, such as the impact of drain timing on resolution of illness severity markers (fever, leukocytosis, hypotension, pressor requirement, SOFA score, etc.) as an example, may demonstrate a difference in these alternative outcome measures without significant difference in mortality or complication rates.

There are several other limitations to our study worth considering. This study is subject to the limitations and potential for observation bias inherent in a retrospective study. Direct communication between services is always recommended, however, any communications that may have influenced the speed of percutaneous interventions are not recorded. It is possible that patients perceived to be sicker may have been prioritized for more rapid intervention resulting in observation bias. Further, we are unable to provide further details as to the reason for readmission, operative intervention, or subsequent IR drain placement. Specifically, we cannot differentiate between patients who required interventions due to a failure of source control compared with other drain-related complications such as leaks, dislodgements, and broken drains. As a single-center study, our findings may not be broadly generalizable. Lastly, we are potentially underpowered to detect smaller differences in outcomes. We are particularly underpowered to detect smaller differences in outcomes for subgroups such as patients with sepsis and/or MOF. Lastly, as an early evaluation of the timing of drain placement, we caution against misinterpreting our findings to suggest that the timing of source control is not important, or that percutaneous drainage should be intentionally delayed. Further work with significantly larger data sets needs to be done to evaluate the impact of timing of percutaneous drainage as the primary method of source control on patient outcomes.

Conclusion

Our findings suggest that within the time frames we observed, the timing of percutaneous intervention is not associated with outcomes for patients with intra-abdominal infections. While we urge caution with interpreting our potentially underpowered study, our findings support the practice of using percutaneous intervention as the primary method of source control in selected patient populations. Future studies should consider evaluating the impact of resolution of markers of illness severity in addition to mortality and complication rates.

Footnotes

Authors’ Contributions

Concept and design: J.C.O., A.R., and C.A.G. Data capture and statistical analysis: J.C.O., A.R., M.J., A.D., and C.A.G. Data interpretation: All authors. Critical article review/critique: All authors.

Author Disclosure Statement

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding Information

The authors received no financial support for the research, authorship, and/or publication of this article.

References

, Zheng

, Hong

, et al. Current progress of source control in the management of intra-abdominal infections. Chin J Traumatol, 2020; 23(6):311–313.

Singer

, Deutschman

, Seymour

, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA, 2016; 315(8):801–810.

Vincent

, Marshall

, Namendys-Silva

, et al.; ICON investigators. Assessment of the worldwide burden of critical illness: The Intensive Care Over Nations (ICON) audit. Lancet Respir Med, 2014; 2(5):380–386.

Fleischmann

, Scherag

, Adhikari

, et al.; International Forum of Acute Care Trialists. Assessment of global incidence and mortality of hospital-treated sepsis. Current estimates and limitations. Am J Respir Crit Care Med, 2016; 193(3):259–272.

Pieracci

, Barie

. Management of severe sepsis of abdominal origin. Scand J Surg, 2007; 96(3):184–196.

Marshall

. Principles of source control in the early management of sepsis. Curr Infect Dis Rep, 2010; 12(5):345–353.

Evans

, Rhodes

, Alhazzani

, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Crit Care Med, 2021; 49(11):e1063–e143.

Huston

, Barie

, Dellinger

, et al.; Therapeutics and Guidelines Committee. The surgical infection society guidelines on the management of intra-abdominal infection: 2024 update. Surg Infect (Larchmt), 2024; 25(6):419–435.

Bloos

, Thomas-Ruddel

, Ruddel

, et al.; MEDUSA Study Group. Impact of compliance with infection management guidelines on outcome in patients with severe sepsis: A prospective observational multi-center study. Crit Care, 2014; 18(2):R42.

10.

Kim

, Chung

, Choi

, et al.; Korean Shock Society (KoSS) Investigators. Impact of timing to source control in patients with septic shock: A prospective multi-center observational study. J Crit Care, 2019; 53:176–182.

11.

Mazuski

, Tessier

, May

, et al. The surgical infection society revised guidelines on the management of intra-abdominal infection. Surg Infect (Larchmt), 2017; 18(1):1–76.

12.

Vincent

, de Mendonca

, Cantraine

, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: Results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European society of intensive care medicine. Crit Care Med, 1998; 26(11):1793–1800.

13.

Evans

, Rhodes

, Alhazzani

, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Intensive Care Med, 2021; 47(11):1181–1247.

14.

Azuhata

, Kinoshita

, Kawano

, et al. Time from admission to initiation of surgery for source control is a critical determinant of survival in patients with gastrointestinal perforation with associated septic shock. Crit Care, 2014; 18(3):R87.

15.

Buck

, Vester-Andersen

, Møller

, Danish Clinical Register of Emergency S. Surgical delay is a critical determinant of survival in perforated peptic ulcer. Br J Surg, 2013; 100(8):1045–1049.

16.

Chao

, Tsai

, Chang

, et al. Impact of timing of surgery on outcome of Vibrio vulnificus-related necrotizing fasciitis. Am J Surg, 2013; 206(1):32–39.

17.

Karvellas

, Abraldes

, Zepeda-Gomez

, et al.; Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group. The impact of delayed biliary decompression and anti-microbial therapy in 260 patients with cholangitis-associated septic shock. Aliment Pharmacol Ther, 2016; 44(7):755–766.

18.

Moss

, Musemeche

, Kosloske

. Necrotizing fasciitis in children: Prompt recognition and aggressive therapy improve survival. J Pediatr Surg, 1996; 31(8):1142–1146.

19.

Wong

, Chang

, Pasupathy

, et al. Necrotizing fasciitis: Clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am, 2003; 85(8):1454–1460.

20.

Ruddel

, Thomas-Ruddel

, Reinhart

, et al.; MEDUSA study group. Adverse effects of delayed antimicrobial treatment and surgical source control in adults with sepsis: Results of a planned secondary analysis of a cluster-randomized controlled trial. Crit Care, 2022; 26(1):51.

21.

Marshall

, Maier

, Jimenez

, et al. Source control in the management of severe sepsis and septic shock: An evidence-based review. Crit Care Med, 2004; 32(11 Suppl):S513–S26.

22.

Van Goor

. Interventional management of abdominal sepsis: When and how. Langenbecks Arch Surg, 2002; 387(5–6):191–200.

23.

Sawyer

, Claridge

, Nathens

, et al.; STOP-IT Trial Investigators. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med, 2015; 372(21):1996–2005.

24.

Rattan

, Allen

, Sawyer

, et al. Percutaneously drained intra-abdominal infections do not require longer duration of antimicrobial therapy. J Trauma Acute Care Surg, 2016; 81(1):108–113.