Peritonitis medical therapy: Difference between revisions

	Peritonitis Main Page
Patient Information
Overview
Causes
Classification Spontaneous Bacterial Peritonitis Secondary Peritonitis
Differential Diagnosis

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Revision as of 21:10, 28 September 2015

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2]

Overview

Medical management of peritonitis includes hydration, prevention of septicemia, and correction of electrolytes. Empiric coverage for gram positive, gram negative, and anaerobic bacteria should be initiated promptly while awaiting culture results. Either open abdominal surgery or an exploratory laparotomy is recommended.

Medical Therapy

Depending on the severity of the patient's state, the management of peritonitis may include:

General supportive measures such as vigorous intravenous rehydration and correction of electrolyte disturbances.
Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum antibiotics often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis; once one or more agents are actually isolated, therapy will of course be targeted on them.

Antibiotic therapy

Peritonitis, spontaneous bacterial

1. Community-acquired Spontaneous Bacterial Peritonitis:^[1]

Preferred regimen (1): Cefotaxime 2 g IV q8h for 5 days
Preferred regimen (2): Ceftriaxone 1 g IV q12h for 5 days
Alternative regimen (penicillin allergy): Levofloxacin 500 mg IV q24h for 5 days

2. Nosocomial Spontaneous Bacterial Peritonitis:^[1]

Preferred regimen: Pipercillin-Tazobactam 3.375 g IV q6h AND Vancomycin 1 g IV q12h for 5 days

3. Vancomycin-resistant Enterococcus Spontaneous Bacterial Peritonitis:^[1]

Preferred regimen: Linezolid 600 mg PO/IV q12h OR Daptomycin 6 mg/kg IV q24h

4. Extended spectrum beta-lactamase Enterobacteriaceae Spontaneous Bacterial Peritonitis(ESBL Enterobacteriaceae SBP):^[1]

Preferred regimen: Meropenem 1 g IV q8h for 5-7 days

Peritonitis, secondary to bowel perforation

1. Community-acquired infection in adults ^[2]

1.1. Mild-to-moderate severity (perforated or abscessed appendicitis and other infections of mild-to-moderate severity):

1.1.1. Single agent:

Preferred regimen (1): Cefoxitin 2 g IV q6h
Preferred regimen (2): Ertapenem 1 g IV q24h
Preferred regimen (3): Moxifloxacin 400 mg IV q24h
Preferred regimen (4): Tigecycline 100 mg single dose THEN 50 mg IV q12h
Preferred regimen (5): Ticarcillin-clavulanic acid 3.1 g IV q6h

1.1.2. Combination:

Preferred regimen (1): Cefazolin 1–2 g IV q8h AND (Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h)
Preferred regimen (2): Cefuroxime 1.5 g IV q8h AND (Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h)
Preferred regimen (3): Ceftriaxone 1–2 g IV q12–24 h AND (Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h)
Preferred regimen (4): Cefotaxime 1–2 g IV q6–8 h AND (Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h)
Preferred regimen (5): Ciprofloxacin 400 mg IV q12h AND (Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h)
Preferred regimen (6): Levofloxacin 750 mg IV q24h AND (Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h)

1.2. High risk or severity (severe physiologic disturbance, advanced age, or immunocompromised state):

1.2.1. Single agent:

Preferred regimen (1): Imipenem 500 mg IV q6h OR 1 g IV q8h
Preferred regimen (2): Meropenem 1 g IV q8h
Preferred regimen (3): Doripenem 500 mg IV q8h
Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h

1.2.2. Combination:

Preferred regimen (1): Cefepime 2 g q8–12h AND Metronidazole 500 mg IV q8–12h or 1500 mg q24h
Preferred regimen (2): Ceftazidime 2 g q8h AND Metronidazole 500 mg IV q8–12h or 1500 mg q24h
Preferred regimen (3): Ciprofloxacin 400 mg q12h AND Metronidazole 500 mg IV q8–12h or 1500 mg q24h
Preferred regimen (4): Levofloxacin 750 mg q24h AND Metronidazole 500 mg IV q8–12h or 1500 mg q24h
Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

2. Health Care–Associated Complicated Intra-abdominal Infection ^[2]

2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other multidrug resistant gram-negative bacilli

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg q8–12h or 1500 mg q24h
Preferred regimen (2): Imipenem 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg IV q8–12h OR 1500 mg q24h
Preferred regimen (3): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg IV every 8–12h OR 1500 mg q24h
Preferred regimen (4): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12h AND Metronidazole 500 mg q8–12h OR 1500 mg q24h
Preferred regimen (5): Imipenem 500 mg IV q6h OR 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12h AND Metronidazole 500 mg IV q8–12h OR 1500 mg q24h
Preferred regimen (6): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12h AND Metronidazole 500 mg IV q8–12h or 1500 mg q24h

2.2 Extended-spectrum B-lactamase-producing Enterobacteriaceae

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (2): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (3): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (4): Imipenem 500 mg IV q6h OR 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (5): Imipenem 500 mg IV q6h OR 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (6): Imipenem 500 mg IV q6h OR 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (7): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (8): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (9): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h

2.3 Pseudomonas aeruginosa with more than 20% resistant to ceftazidime

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (2): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (3): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (7): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (8): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (9): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h

2.4 Methicillin-resistant Staphylococcus aureus (MRSA)

Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

Peritonitis, secondary to dialysis

1. Mild-moderate disease^[3]

Preferred regimen (1): Piperacillin-tazobactam 3.375 g IV q6h OR 4.5 g IV q8h
Preferred regimen (2): Ticarcillin-clavulanate 3.1 g IV q6h.
Alternative regimen (1): Ciprofloxacin 400 mg IV q12h AND Metronidazole 1 g IV q12h
Alternative regimen (2): Levofloxacin 750 mg IV q24h AND Metronidazole 1 g IV q12h.

2. Severe life-threatening disease^[4]

Preferred regimen (1): Imipenem 500 mg IV q6h
Preferred regimen (2): Meropenem 1 g IV q8h

Peritonitis, secondary to ruptured appendix

1. Community-acquired infection in adults ^[2]

1.1. Mild-to-moderate severity (perforated or abscessed appendicitis and other infections of mild-to-moderate severity):

1.1.1. Single agent:

Preferred regimen (1): Cefoxitin 2 g IV q6h
Preferred regimen (2): Ertapenem 1 g IV q24h
Preferred regimen (3): Moxifloxacin 400 mg IV q24h
Preferred regimen (4): Tigecycline 100 mg initial dose, THEN 50 mg IV q12h
Preferred regimen (5): Ticarcillin-clavulanic acid 3.1 g IV q6h; FDA labeling indicates 200 mg/kg/day in divided doses every 6 h for moderate infection

1.1.2. Combination:

Preferred regimen (1): Cefazolin 1–2 g IV q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (2): Cefuroxime 1.5 g IV q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (3): Ceftriaxone 1–2 g IV q12–24 h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (4): Cefotaxime 1–2 g IV q6–8 h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (5): Ciprofloxacin 400 mg IV q12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (6): Levofloxacin 750 mg IV q24h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h

1.2. High risk or severity (severe physiologic disturbance, advanced age, or immunocompromised state):

1.2.1. Single agent:

Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h
Preferred regimen (2): Meropenem 1 g IV q8h
Preferred regimen (3): Doripenem 500 mg IV q8h
Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h

1.2.2. Combination:

Preferred regimen (1): Cefepime 2 g q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (2): Ceftazidime 2 g q8h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (3): Ciprofloxacin 400 mg q12h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (4): Levofloxacin 750 mg q24h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

2. Health Care–Associated Complicated Intra-abdominal Infection ^[2]

2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other multidrug resistant gram-negative bacilli:

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg q8–12 h or 1500 mg q24h
Preferred regimen (2): Imipenem-cilastatin 500 mg IV 6 h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (3): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg IV every 8–12 h or 1500 mg q24h
Preferred regimen (4): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12 h AND Metronidazole 500 mg q8–12 h or 1500 mg q24h
Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (6): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h

2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (2): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (3): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (7): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (8): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (9): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h

2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (2): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (3): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (7): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (8): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (9): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h

2.4.Methicillin-resistant Staphylococcus aureus (MRSA):

Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12 h
Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

3. Community-acquired infection in pediatric patients

3.1. Single agent:

Preferred regimen (1): Ertapenem 3 months to 12 years 15 mg/kg bid (not to exceed 1 g/day) Every 12 h, older than 13 years 1 g/day Every 24 h OR
Preferred regimen (2): Meropenem 60 mg/kg/day q8h
Preferred regimen (3): Imipenem-cilastatin 60–100 mg/kg/day IV q6h
Preferred regimen (4): Ticarcillin-clavulanate 200–300 mg/kg/day IV of ticarcillin component q4–6 h
Preferred regimen (5): Piperacillin-tazobactam 200–300 mg/kg/day IV of piperacillin component q6–8 h

3.2.Combination:

Preferred regimen(1): Ceftriaxone 50–75 mg/kg/day q12–24 h, AND Metronidazole 30–40 mg/kg/day q8h
Preferred regimen(2): Cefotaxime 150–200 mg/kg/day q6–8 h, AND Metronidazole 30–40 mg/kg/day q8h
Preferred regimen(3): Cefepime 100 mg/kg/day q12h, AND Metronidazole 30–40 mg/kg/day q8h
Preferred regimen(4): Ceftazidime 150 mg/kg/day q8 h, AND Metronidazole 30–40 mg/kg/day q8h
Preferred regimen(5): Gentamicin 3–7.5 mg/kg/day q2–4 h, AND Metronidazole 30–40 mg/kg/day q8h ± Ampicillin 200 mg/kg/day q6h
Preferred regimen(6): Gentamicin 3–7.5 mg/kg/day q2–4 h, AND Clindamycin 20–40 mg/kg/day q6–8 h ± Ampicillin 200 mg/kg/day q6h
Preferred regimen(7): Tobramycin 3.0–7.5 mg/kg/day q8–24 h, AND Metronidazole 30–40 mg/kg/day q8h ± Ampicillin 200 mg/kg/day q6h
Preferred regimen(8): Tobramycin 3.0–7.5 mg/kg/day q8–24 h, AND Clindamycin 20–40 mg/kg/day q6–8 h ± Ampicillin 200 mg/kg/day q6h
Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

Peritonitis, secondary to ruptured diverticula

1. Community-acquired infection in adults ^[2]

1.1. Mild-to-moderate severity (perforated or abscessed appendicitis and other infections of mild-to-moderate severity):

1.1.1. Single agent:

Preferred regimen (1): Cefoxitin 2 g IV q6h
Preferred regimen (2): Ertapenem 1 g IV q24h
Preferred regimen (3): Moxifloxacin 400 mg IV q24h
Preferred regimen (4): Tigecycline 100 mg initial dose, THEN 50 mg IV q12h
Preferred regimen (5): Ticarcillin-clavulanic acid 3.1 g IV q6h; FDA labeling indicates 200 mg/kg/day in divided doses every 6 h for moderate infection

1.1.2. Combination:

Preferred regimen (1): Cefazolin 1–2 g IV q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (2): Cefuroxime 1.5 g IV q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (3): Ceftriaxone 1–2 g IV q12–24 h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (4): Cefotaxime 1–2 g IV q6–8 h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (5): Ciprofloxacin 400 mg IV q12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (6): Levofloxacin 750 mg IV q24h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h

1.2. High risk or severity (severe physiologic disturbance, advanced age, or immunocompromised state):

1.2.1. Single agent:

Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h
Preferred regimen (2): Meropenem 1 g IV q8h
Preferred regimen (3): Doripenem 500 mg IV q8h
Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h

1.2.2. Combination:

Preferred regimen (1): Cefepime 2 g q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (2): Ceftazidime 2 g q8h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (3): Ciprofloxacin 400 mg q12h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (4): Levofloxacin 750 mg q24h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

2. Health Care–Associated Complicated Intra-abdominal Infection ^[2]

2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other multidrug resistant gram-negative bacilli:

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg q8–12 h or 1500 mg q24h
Preferred regimen (2): Imipenem-cilastatin 500 mg IV 6 h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (3): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg IV every 8–12 h or 1500 mg q24h
Preferred regimen (4): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12 h AND Metronidazole 500 mg q8–12 h or 1500 mg q24h
Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (6): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h

2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (2): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (3): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (7): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (8): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (9): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h

2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (2): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (3): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (7): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (8): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (9): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h

2.4.Methicillin-resistant Staphylococcus aureus (MRSA):

Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12 h
Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 Dever JB, Sheikh MY (2015). "Review article: spontaneous bacterial peritonitis - bacteriology, diagnosis, treatment, risk factors and prevention". Aliment Pharmacol Ther. 41 (11): 1116–31. doi:10.1111/apt.13172. PMID 25819304.
↑ ^2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ; et al. (2010). "Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America". Clin Infect Dis. 50 (2): 133–64. doi:10.1086/649554. PMID 20034345.
↑ Ferri, Fred (2015). Ferri's Clinical Advisor 2016: 5 Books in 1, 1e (Ferri's Medical Solutions). ISBN 978-0323280471.
↑ Ferri, Fred (2015). Ferri's Clinical Advisor 2016: 5 Books in 1, 1e (Ferri's Medical Solutions). ISBN 978-0323280471.

Template:WikiDoc Sources

[pmid25819304-1] 1.0 ^1.1 ^1.2 ^1.3 Dever JB, Sheikh MY (2015). "Review article: spontaneous bacterial peritonitis - bacteriology, diagnosis, treatment, risk factors and prevention". Aliment Pharmacol Ther. 41 (11): 1116–31. doi:10.1111/apt.13172. PMID 25819304.

[pmid20034345-2] 2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ; et al. (2010). "Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America". Clin Infect Dis. 50 (2): 133–64. doi:10.1086/649554. PMID 20034345.

[3] Ferri, Fred (2015). Ferri's Clinical Advisor 2016: 5 Books in 1, 1e (Ferri's Medical Solutions). ISBN 978-0323280471.

[4] Ferri, Fred (2015). Ferri's Clinical Advisor 2016: 5 Books in 1, 1e (Ferri's Medical Solutions). ISBN 978-0323280471.

[1]

[2]

[3]

[4]

@@ Line 36: / Line 36: @@
 :::*Preferred regimen (2): [[Ertapenem]] 1 g IV q24h
 :::*Preferred regimen (3): [[Moxifloxacin]] 400 mg IV q24h
-:::*Preferred regimen (4): [[Tigecycline]] 100 mg initial dose, {{then}} 50 mg IV q12h
+:::*Preferred regimen (4): [[Tigecycline]] 100 mg single dose {{then}} 50 mg IV q12h
-:::*Preferred regimen (5): [[Ticarcillin]]-[[clavulanic acid]] 3.1 g IV q6h; FDA labeling indicates 200 mg/kg/day in divided doses every 6 h for moderate infection
+:::*Preferred regimen (5): [[Ticarcillin]]-[[clavulanic acid]] 3.1 g IV q6h
 ::*'''1.1.2. Combination:'''
-:::*Preferred regimen (1): [[Cefazolin]] 1–2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:::*Preferred regimen (1): [[Cefazolin]] 1–2 g IV q8h {{and}} ([[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h)
-:::*Preferred regimen (2): [[Cefuroxime]] 1.5 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:::*Preferred regimen (2): [[Cefuroxime]] 1.5 g IV q8h {{and}} ([[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h)
-:::*Preferred regimen (3): [[Ceftriaxone]] 1–2 g IV q12–24 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:::*Preferred regimen (3): [[Ceftriaxone]] 1–2 g IV q12–24 h {{and}} ([[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h)
-:::*Preferred regimen (4): [[Cefotaxime]] 1–2 g IV  q6–8 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:::*Preferred regimen (4): [[Cefotaxime]] 1–2 g IV  q6–8 h {{and}} ([[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h)
-:::*Preferred regimen (5): [[Ciprofloxacin]] 400 mg IV q12h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:::*Preferred regimen (5): [[Ciprofloxacin]] 400 mg IV q12h {{and}} ([[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h)
-:::*Preferred regimen (6): [[Levofloxacin]] 750 mg IV  q24h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:::*Preferred regimen (6): [[Levofloxacin]] 750 mg IV  q24h {{and}} ([[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h)
 :*'''1.2. High risk or severity (severe physiologic disturbance, advanced age, or immunocompromised state):'''
 ::*'''1.2.1. Single agent:'''
-:::*Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h
+:::*Preferred regimen (1): [[Imipenem]] 500 mg IV q6h {{or}} 1 g IV q8h
 :::*Preferred regimen (2): [[Meropenem]] 1 g IV q8h
 :::*Preferred regimen (3): [[Doripenem]] 500 mg IV q8h
@@ Line 55: / Line 55: @@
 ::*'''1.2.2. Combination:'''
-:::*Preferred regimen (1): [[Cefepime]] 2 g  q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+:::*Preferred regimen (1): [[Cefepime]] 2 g  q8–12h {{and}} [[Metronidazole]] 500 mg IV q8–12h or 1500 mg q24h
-:::*Preferred regimen (2): [[Ceftazidime]] 2 g q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+:::*Preferred regimen (2): [[Ceftazidime]] 2 g q8h {{and}} [[Metronidazole]] 500 mg IV q8–12h or 1500 mg q24h
-:::*Preferred regimen (3): [[Ciprofloxacin]] 400 mg q12h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+:::*Preferred regimen (3): [[Ciprofloxacin]] 400 mg q12h {{and}} [[Metronidazole]] 500 mg IV q8–12h or 1500 mg q24h
-:::*Preferred regimen (4): [[Levofloxacin]]  750 mg q24h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+:::*Preferred regimen (4): [[Levofloxacin]]  750 mg q24h {{and}} [[Metronidazole]] 500 mg IV q8–12h or 1500 mg q24h
 :::*Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.
 *'''2. Health Care–Associated Complicated Intra-abdominal Infection''' <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
-:*'''2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other  multidrug resistant gram-negative bacilli:'''
+:*'''2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other  multidrug resistant gram-negative bacilli'''
-::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
+::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg q8–12h or 1500 mg q24h
-::*Preferred regimen (2): Imipenem-cilastatin 500 mg IV 6 h {{or}} 1 g  q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+::*Preferred regimen (2): [[Imipenem]] 500 mg IV q6h {{or}} 1 g  q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12h {{or}} 1500 mg q24h
-::*Preferred regimen (3): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV every 8–12 h or 1500 mg q24h
+::*Preferred regimen (3): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV every 8–12h {{or}} 1500 mg q24h
-::*Preferred regimen (4): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
+::*Preferred regimen (4): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12h {{and}} [[Metronidazole]] 500 mg q8–12h {{or}} 1500 mg q24h
-::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+::*Preferred regimen (5): [[Imipenem]] 500 mg IV q6h {{or}} 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12h {{and}} [[Metronidazole]] 500 mg IV q8–12h {{or}} 1500 mg q24h
-::*Preferred regimen (6): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+::*Preferred regimen (6): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12h {{and}} [[Metronidazole]] 500 mg IV q8–12h or 1500 mg q24h
-:*'''2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:'''
+:*'''2.2 Extended-spectrum B-lactamase-producing Enterobacteriaceae'''
-::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (1): [[Meropenem]] 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
-::*Preferred regimen (2): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (2): [[Meropenem]] 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
-::*Preferred regimen (3): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
+::*Preferred regimen (3): [[Meropenem]] 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
-::*Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (4): [[Imipenem]] 500 mg IV q6h {{or}} 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
-::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (5): [[Imipenem]] 500 mg IV q6h {{or}} 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
-::*Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
+::*Preferred regimen (6): [[Imipenem]] 500 mg IV q6h {{or}} 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
-::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
-::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
-::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
+::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
-:*'''2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:'''
+:*'''2.3 Pseudomonas aeruginosa with more than 20% resistant to ceftazidime'''
 ::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
 ::*Preferred regimen (2): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
@@ Line 92: / Line 92: @@
 ::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
-:*'''2.4.Methicillin-resistant Staphylococcus aureus (MRSA):'''
+:*'''2.4 Methicillin-resistant Staphylococcus aureus (MRSA)'''
-::*Preferred regimen: [[Vancomycin]] 15–20 mg/kg IV q8–12 h
+::*Preferred regimen: [[Vancomycin]] 15–20 mg/kg IV q8–12h
 ::*Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.