BACKGROUND: Timing and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted. METHODS: This worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018. RESULTS: A total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47 years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6 days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80 years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate ≥ 22 breaths/min, systolic blood pressure < 100 mmHg, AVPU responsiveness scale (voice and unresponsive), blood oxygen saturation level (SpO2) < 90% in air, platelet count < 50,000 cells/mm3, and lactate > 4 mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8. CONCLUSIONS: The simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.

1st Clinic of General Surgery University Hospital St George Medical University Plovdiv Plovdiv Bulgaria

1st Department of Surgery Department of Abdominal Thoracic Surgery and Traumatology 1st Faculty of Medicine Charles University and General University Hospital Prague Czech Republic

1st Department of Surgery Kavala General Hospital Kavala Greece

1st Department of Surgery Tzaneio General Hospital Piraeus Greece

1st Surgical Unit St Spiridon University Hospital Iasi University of Medicine and Pharmacy Grigore T Popa Iasi Romania

2 Catedra de Clinica Quirúrgica Hospital de Clinicas Facultad de Ciencias Médicas Universidad Nacional de Asunción Asunción Paraguay

2nd Surgical Clinic Emergency County Hospital of Craiova Craiova Romania

582nd Department of Surgery Aretaieion University Hospital National and Kapodistrian University of Athens Athens Greece

664th Surgical Department Medical School Aristotle University of Thessaloniki General Hospital G Papanikolaou Thessaloniki Greece

902nd Department of General Surgery Jagiellonian University Medical College Kraków Poland

983rd Department of Surgery Ahepa University Hospital Thessaloniki Greece

993rd Department of Surgery Attikon University Hospital Athens Greece

Abdominal Center Department of Abdominal Surgery Helsinki University Hospital Meilahti and University of Helsinki Helsinki Finland

Chirurgia d'Urgenza Arcispedale Santa Maria Nuova IRCCS Reggio Emilia Italy

Chirurgia d'Urgenza Dipartimento Urgenza Emergenza AOU Parma Parma Italy

Chirurgia Generale e d'Urgenza Ospedale Infermi Rimini Italy

Chirurgia Generale Ospedale Civile di Guastalla Reggio Emilia Italy

Chirurgia Generale Ospedale Versilia La Spezia Italy

Chirurgia generale Sant'Anna Castelnovo ne' Monti Italy

Chirurgie Générale et Viscérale Hôpital d'instruction des Armées Hôpital Principal de Dakar Dakar Senegal

Chirurgie Viscerale et d'Urgence Centre Hospitalier Regional de Perpignan Perpignan France

Chirurgische Abteilung Landesklinikum Hainburg Hainburg an der Donau Austria

Cirugía general y del aparato digestivo Hospital Universitario Donostia Donostia Spain

Cirurgia Geral Centro Hospitalar Tondela Viseu Viseu Portugal

Cirurgia Geral Centro Hospitalar Universitário da Cova da Beira Covilhã Portugal

Cirurgia Geral Hospital de Braga Life and Health Sciences Research Institute ICVS 3Bs Universidade do Minho Braga Portugal

Departament of General Surgery Hospital Municipal de Governador Valadares Vale do Rio Doce University Governador Valadares Brazil

Department of Abdominal Surgery UMC Ljubljana Ljubljana Slovenia

Department of Abdominal Surgery Vladimir City Clinical Hospital of Emergency Medicine Vladimir Russia

Department of Clinical and Experimental Sciences University of Brescia Brescia Italy

Department of Digestive Surgery and SSPC Research Unit CHU Amiens Picardie Amiens France

Department of Emergency Surgery Bufalini Hospital Cesena Italy

Department of Emergency Surgery City Hospital Mozyr Belarus

Department of Endoscopic Metabolic and Soft Tissue Tumors Surgery University Hospital Kraków Poland

Department of Faculty Surgery 1 Pirogov Russian National Research Medical University Moscow Russia

Department of Gastrointestinal Surgery HGR1 IMSS Cuernavaca Mexico

Department of Gastrointestinal Surgery University of Health Sciences Elazig Training and Research Hospital Elazig Turkey

Department of General and Digestive Surgery Hospital Universitario Doctor Peset Valencia Spain

Department of General and Emergency Surgery ASMN Reggio Emilia Modena Italy

Department of General and Emergency Surgery ASST Monza Ospedale San Gerardo Monza Italy

Department of General and Emergency Surgery Azienda Ospedaliera Policlinico Universitario Palermo Paolo Giaccone Palermo Italy

Department of General and Emergency Surgery University Hospital University Hospital Kraków Kraków Poland

Department of General and Thoracic Surgery University Hospital of Giessen Giessen Germany

Department of General Emergency and Robotic Surgery San Francesco Hospital Nuoro Italy

Department of General Oncologic and Geriatric Surgery Jagiellonian University Collegium Medicum Kraków Poland

Department of General Oncological Metabolic and Thoracic Surgery Military Institute of Medicine Warsaw Poland

Department of General Surgery and Surgical Oncology Policlinico Le Scotte University of Siena Siena Italy

Department of General Surgery Ankara University School of Medicine Ankara Turkey

Department of General Surgery Erzincan University Hospital Erzincan Turkey

Department of General Surgery General Hospital of Trikala Trikala Greece

Department of General Surgery Government Medical College and Hospital Chandigarh India

Department of General Surgery Hacettepe University Hospital Ankara Turkey

Department of General Surgery Hadassah Medical Center Jerusalem Israel

Department of General Surgery Istinye University Faculty of Medicine Istanbul Turkey

Department of General Surgery Karadeniz Technical University Trabzon Turkey

Department of General Surgery Kasturba Medical College Manipal Academy of Higher Education Manipal India

Department of General Surgery Kuala Krai Hospital Kuala Krai Malaysia

Department of General Surgery Mansoura University Hospital Mansoura Egypt

Department of General Surgery Miguel Servet Zaragoza Spain

Department of General Surgery Polytrauma and Emergency Medicine University Hospital of the Jagiellonian University Medical College Kraków Poland

Department of General Surgery Post graduate Institute of Medical Sciences Rohtak India

Department of General Surgery Queen Elizabeth Hospital London UK

Department of General Surgery Rambam Health Care Campus Haifa Israel

Department of General Surgery Sakarya University Research and Educational Hospital Sakarya Turkey

Department of General Surgery San Salvatore Pesaro Italy

Department of General Surgery Siirt State Hospital Siirt Turkey

Department of General Surgery Tan Tock Seng Hospital Singapore Singapore

Department of General Surgery University and Regional Hospital Center of Borgou Parakou Republic of Benin

Department of General Surgery University Hospital of Coventry and Warwickshire Coventry UK

Department of General Surgery University Hospital of Trauma Tirana Albania

Department of General Surgery University of Health Sciences Elazig Training and Research Hospital Elazig Turkey

Department of Infectious Diseases King Fahad Medical City Riyadh Saudi Arabia

Department of Primary Care Primary Health Care Centre of Kissamos Chania Greece

Department of Specialist Surgery Port Shepstone Regional Hospital Port Shepstone Republic of South Africa

Department of Surgery AO San Giovanni Addolorata Rome Italy

Department of Surgery Athens Naval and Veterans Hospital Athens Greece

Department of Surgery Clinical Center University of Pecs Pecs Hungary

Department of Surgery College of Health Sciences Obafemi Awolowo University Ile Ife Nigeria

Department of Surgery College of Medicine and Health Sciences UAE University Al Ain United Arab Emirates

Department of Surgery Elias Emergency Hospital Bucharest Romania

Department of Surgery Fatebbenefratelli Hospital Isola Tiberina Rome Italy

Department of Surgery Fundacion Valle del Lili Universidad del Valle Cali Colombia

Department of Surgery G Da Saliceto Hospital Piacenza Italy

Department of Surgery Hassan 2 Fez Morocco

Department of Surgery Hospital and Oncological Centre Novy Jicin Novy Jicin Czech Republic

Department of Surgery Hospital of Lithuanian University of Health Sciences Kaunas Clinics Kaunas Lithuania

Department of Surgery Hospital San Juan de Dios de La Serena La Serena Chile

Department of Surgery Hospital Universitário Terezinha de Jesus Faculdade de Ciências Médicas e da Saúde de Juiz de Fora Juiz de Fora Brazil

Department of Surgery Inje University Ilsan Paik Hospital Goyang Republic of Korea

Department of Surgery King George's Medical University Lucknow India

Department of Surgery Kipshidze Central University Hospital Tbilisi Georgia

Department of Surgery Krishna Hospital and Medical Research University Karad Karad India

Department of Surgery LAUTECH Teaching Hospital Osogbo Nigeria

Department of Surgery Lumbini Medical College and Teaching Hospital Ltd Tansen Palpa Nepal

Department of Surgery Macerata Hospital Macerata Italy

Department of Surgery Mansoura University and Emergency Hospital Mansoura Egypt

Department of Surgery Mosc Medical College Kolenchery Cochin India

Department of Surgery Radiology Anaesthesia and Intensive Care University Hospital of the West Indies Kingston Jamaica

Department of Surgery Riga East Clinical University Hospital Gaiļezers Riga Latvia

Department of Surgery Saint Savvas Anticancer Hospital Athens Greece

Department of Surgery San Carlo Borromeo Hospital Milan Italy

Department of Surgery Sant'Antonio Abate Hospital Gallarate Italy

Department of Surgery SMS Hospital Jaipur India

Department of Surgery Taipei Medical University Hospital Taipei Taiwan

Department of Surgery Tianjin Nankai Hospital Tianjin China

Department of Surgery Trauma Hospital Santo Tomás Panama Panama

Department of Surgery TSMU 1st University Clinic Tbilisi Georgia

Department of Surgery University Clinical Center Tuzla Tuzla Bosnia and Herzegovina

Department of Surgery University hospital Amiens France

Department of Surgery University Hospital Centre Zagreb Zagreb Croatia

Department of Surgery University of Ilorin Teaching Hospital Ilorin Nigeria

Department of Surgey Zliten Teaching Hospital Zliten Libya

Department of Surgical Disciplines Regional Clinical Hospital Immanuel Kant Baltic Federal University Kaliningrad Russia

Department of Surgical Oncology King Fahad Medical City Riyadh Saudi Arabia

Department of Trauma ICU IALCH University of KwaZulu Natal Durban South Africa

Department of Vascular Surgery City Hospital Mozyr Belarus

Dipartimento Emergenza e Accettazione Policlinico Umberto 1 Roma Italy

Division of Trauma and Acute Care Surgery LAC USC Medical Center Los Angeles USA

Division of Trauma Surgery Hospital de Clinicas University of Campinas Campinas Brazil

Emergency and General Surgery SG Bosco Torino Italy

Emergency Surgery Department Maggiore Parma Hospital Parma Italy

Faculty of Medicine and Biomedical Sciences University of Yaounde 1 Yaounde Cameroon and Department of Surgery and Anaesthesiology Yaounde Central Hospital Yaounde Cameroon

Faculty of Medicine University of Belgrade Clinic for Surgery University Clinical Center Zvezdara Belgrade Serbia

Gastrointestinal Surgery Hospital Insular de Gran Canaria Las Palmas de Gran Canaria Spain

General Acute Care Abdominal Wall Reconstruction and Trauma Surgery Foothills Medical Centre Calgary AB Canada

General and Digestive Surgery Hospital Fundación Jimenez Diaz Madrid Spain

General Surgery Department Bukovinian State Medical University Chernivtsi Ukraine

General Surgery Department Emergency Hospital of Bucharest Bucharest Romania

General Surgery Habib bougatfa Bizerte Tunisia

General Surgery Heartlands Hospital Birmingham UK

General Surgery Hospital Santo Tomas Panama Panama

General Surgery Scarborough Hospital York Teaching Hospital NHS FT York UK

General Surgery South Warwickshire NHS Foundation Trust Warwick UK

General Surgery University of Health Sciences Samsun Training and Research Hospital Samsun Turkey

General Visceral Thoracic and Vascular Surgery University Hospital Greifswald Greifswald Germany

Global Alliance for Infections in Surgery Porto Portugal

Intensive Care Unit Chernivtsi City Emergency Hospital Chernivtsi Ukraine

Medicina Base Hospital Bauru Brazil

Renal Transplant and General Surgery Manchester Royal Infirmary Manchester UK

Surgery Department Chernivtsi City Emergency Hospital Chernivtsi Ukraine

Surgery Department Tbilisi State Medical University Tbilisi Georgia

Surgical Department and ICU Department General Hospital of Larissa Larissa Greece

Surgical Department UMHAT Eurohospital Medical University Plovdiv Bulgaria

Surgical Oncology Unit Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy

Surgical Oncology University Hospital Heraclion Crete Heraclion Crete Greece

Toxicology and Sepsis Riga East University Hospital Riga Latvia

Transplantation Unıt Acibadem Atakent Hospital İstanbul Turkey

Trauma and Acute Care Surgery Edendale Hospital Pietermaritzburg South Africa

Trauma and Emergency Surgery Hospital Escola Padre Albino Catanduva Brazil

U O C Chirurgia Generale PO Santissima Trinità Cagliari Italia

U O Chirurgia d'Urgenza Arcispedale S Anna Ferrara Ferrara Italy

U O Chirurgia d'Urgenza Universitaria Azienda Ospedaliero Universitaria Pisana Pisa Italy

UGC Cirugía General Complejo Hospitalario de Jaén Jaén Spain

Upper Gastrointestinal Tract Surgery Department North Estonia Medical Centre Tallinn Estonia

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