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intra-abdominal infection

Etiology: 1) intestinal perforation 2) abdominal surgery 3) appendicitis (community-acquired) 4) cholangitis, cholecystitis (healthcare-associated) 4) diverticulitis 5) infection associates with pancreatitis 6) peritonitis Management: 1) empiric antibiotics (general) a) gram-positive, gram negative & anaerobe coverage b) oral antibiotics ok; IV not needed [4] c) suggested regimens - metronidazole plus ceftazidime, cefepime or ciprofloxacin [4] - others - moxifloxacin (monotherapy) - amoxicillin clavulanate - piperacillin-tazobactam may not provide coverage of Enterococcus faecalis - imipenem-cilastatin, meropenem, doripenem 2) healthcare-associated infection a) target gram-negative aerobic & facultative bacilli: b) enterococcal coverage recommended, especially if post-op, prior cephalosporin use, immunocompromised, or patient has valvular heart disease or prosthetic vascular material c) target vancomycin-resistant Enterococcus (VRE) in very high-risk patients (known colonization, liver transplant with infection of hepatobiliary origin) d) MRSA suspected (known colonization, prior antibiotic failure) - vancomycin first-line - quinupristin-dalfopristin, linezolid, daptomycin, & tigecycline have in vitro activity e) guidelines do not recommend specific drug for VRE coverage f) infectious disease consult 3) duration of antibiotic therapy - 4 days of therapy may be sufficient after source has been controlled ( (ie, percutaneous or surgical drainage) [3] - antibiotic treatment for 8 versus 15 days reduces antibiotic exposure without compromising outcomes in critically ill patients with postoperative intra-abdominal infection (also see postoperative infection) 4) surgery - drainage of abscess, peritoneal effusion etc

General

infection (infectious disease)

References

  1. Malangoni MA et al, Randomized controlled trial of moxifloxacin compared with piperacillin-tazobactam and amoxicillin-clavulanate for the treatment of complicated intra-abdominal infections. Ann Surg 2006, 244:204 PMID: 16858182
  2. Prescriber's Letter 17(3): 2010 CHART: Antibiotics for Complicated Intra-Abdominal Infections GUIDELINES: Diagnosis and Management of Complicated Intra- abdominal Infections Detail-Document#: 260321 (subscription needed) http://www.prescribersletter.com
  3. Sawyer RG et al Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection. N Engl J Med 2015; 372:1996-2005. May 21, 2015. PMID: 25992746 http://www.nejm.org/doi/full/10.1056/NEJMoa1411162 - Wenzel RP, Edmond MB Antibiotics for Abdominal Sepsis. N Engl J Med 2015; 372:2062-2063. May 21, 2015. PMID: 25992751 http://www.nejm.org/doi/full/10.1056/NEJMe1503936
  4. Medical Knowledge Self Assessment Program (MKSAP) 17, American College of Physicians, Philadelphia 2015
  5. Montravers P, Tubach F, Lescot T et al. Short-course antibiotic therapy for critically ill patients treated for postoperative intra-abdominal infection: The DURAPOP randomised clinical trial. Intensive Care Med. 2018 Mar;44(3):300-310 PMID: 29484469 https://link.springer.com/article/10.1007%2Fs00134-018-5088-x