Sandbox/intraabdominal

Overview

From a clinical view, intra-abdominal infections can be classified in: 1) uncomplicated, in which the infectious process involves only a single organ and there is no anatomical disruption, and 2) complicated, in which the infectious process extends beyond the hollow viscus into the peritoneal space and is associated with abscess formation or peritonitits. Patients with uncomplicated intra-abdominal infections usually do not need antimicrobial therapy besides perioperative prophylaxis and can be managed with surgery alone (i.e. appendicitis).

Principles of Therapy for Complicated Intra-abdominal Infection

• Clinical factors for high risk patients:
  • Delay in the initial intervention (>24) h)
  • APACHE II score of 15 or more.
  • Advanced age (>70 years)
  • Comorbidity and degree of organ dysfunction
  • Low albumin level
  • Poor nutrition status
  • Degree of peritoneal involvement or diffuse peritonitis
  • Inability to achieve adequate debridement or control of drainage
  • Presence of malignancy
• All patients should undergo a source control procedure to drain infected foci, control ongoing peritoneal contamination by diversion or resection, and restore anatomic and physiological function.
• Patients should undergo rapid fluid resuscitation and other measures in order to promote physiological stability.FOr patienst with septic shock or organ failure, follow THe Surviving Sepsis Campaign guidelines for managing septic shock.
• Antibiotics should be initiated once the diagnosis of intra-abdominal infection is established or once such infection is considered highly likely.
• Patients without septic shock should receive antimicrobial therapy in the emergency department.
• For patients with lower-risk with co community-acquired infection, cultures are optional. For higher-risk patients, cultures from the site of infection should be obtained.
• Susceptibility testing for Pseudomonas, Proteus, Acinetobacter, Staphylococcus aureus, and Enterobacteriaceae should be performed.
• Lower-risk patients with community-acquired intra-abdominal infection do not require modification of therapy if they show a satisfactory clinical response to source control and medical therapy.
• Use of susceptibility results to determine antibiotic therapy in high-severity community-acquired or health care-associated infection should be based on pathogenic potential and density of identified organisms.
• The duration of therapy should be limited to 4-7 days.

Initial Empiric Treatment of Extra-biliary Community-acquired Complicated Intra-abdominal Infection

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Pediatric patients   ▸  Single agent   ▸  Combination Adults, mild-to-moderate severity   ▸  Single agent   ▸  Combination Adults, high risk or severity   ▸  Single agent   ▸  Combination

Single agent ▸ Ertapenem 3 months to 12 years 15 mg/kg IV q12h; >13 years 1 g IV q24h OR ▸ Meropenem 60 mg/kg/day IV q8h OR ▸ Imipenem/Cilastatin 60-100 mg/kg/day IV q4-6h OR ▸ Ticarcillin-Clavulanate 200-300 mg/kg/day IV q12h OR ▸ Piperacillin-Tazobactam 200-300 mg/kg/day IV q6-8h Combination ▸ Ceftriaxone 50-70 mg/kg/day IV q12-24h OR ▸ Cefotaxime 150-200 mg/kg/day IV q6-8h OR ▸ Cefepime 100 mg/kg/day IV q12h OR ▸ Ceftazidime 150 mg/kg/day IV q8h PLUS ▸ Metronidazole 30-40 mg/kg/day IV q8h OR ▸ Gentamicin 3-7.5 mg/kg/day IV q2-4h OR ▸ tobramycin 3-7.5 mg/kg/day IV q8-24h PLUS ▸ Metronidazole 30-40 mg/kg/day IV q8h OR ▸ Clindamycin 20-40 mg/kg/day IV q6-8h WITH OR WITHOUT ▸ Ampicillin 200 mg/kg/day IV q8-24h Single agent ▸ Cefoxitin 2 g IV q6h OR ▸ Ertapenem 1 g IV q24h OR ▸ Moxifloxacin 400 mg IV q24h OR ▸ Tigecycline 100 mg initial dose, then 50 mg IV q12h OR ▸ Ticarcillin-Clavulanic acid 200 mg/kg/day IV q6h Combination ▸ Cefazolin 1-2 g IV q8h OR ▸ Cefuroxime 1.5 g IV q8h OR ▸ Ceftriaxone 1-2 g IV q12-24h OR ▸ Cefotaxime 1-2 g IV q6-8h OR ▸ Ciprofloxacin 400 mg IV q12h OR ▸ Levofloxacin 750 mg IV q24h PLUS ▸ Metronidazole 500 mg IV q8-12h or 1.5 g q24h Single agent ▸ Imipenem-Cilastatin 500 g IV q6h or 1 g q8h OR ▸ Meropenem 1 g IV q8h OR ▸ Doripenem 500 g IV q8h OR ▸ Piperacillin-Tazobactam 3.375 g IV q6h† † For Pseudomonas aeruginosa may be increased to 3.375 g q4h or 4.5 g q6h . Combination ▸ Cefepime 2 g IV q8-12h OR ▸ Ceftazidime 2 g IV q8h OR ▸ Ciprofloxacin 400 g IV q12h OR ▸ Levofloxacin 750 mg IV q24h PLUS ▸ Metronidazole 500 mg IV q8-12h or 1.5 g q24h

Empiric Antimicrobial Therapy for Health Care-Associated Complicated Intra-abdominal Infection

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Multidrug resistant gram-negative bacilli   ▸  Recommended Regimen ESBL-Enterobacteriaceae   ▸  Recommended Regimen Pseudomonas aeruginosa >20% resistant to ceftazidime   ▸  Recommended Regimen MRSA   ▸  Recommended Regimen

Recommended Regimen Carbapenem ▸ Meropenem 1 g IV q8h OR ▸ Imipenem/Cilastatin 500 g IV q6h or 1 g q8h OR ▸ Doripenem 500 g IV q8h Cephalosporin-based ▸ Ceftazidime 200-300 mg/kg/day IV q12h OR ▸ Cefepime 200-300 mg/kg/day IV q12h PLUS ▸ Metronidazole 500 mg IV q8-12h or 1.5 g q24h Penicillin-based ▸ Piperacillin-Tazobactam 3.375 g q4h or 4.5 g q6h Recommended Regimen Carbapenem ▸ Meropenem 1 g IV q8h OR ▸ Imipenem/Cilastatin 500 g IV q6h or 1 g q8h OR ▸ Doripenem 500 g IV q8h Penicillin-based ▸ Piperacillin-Tazobactam 3.375 g IV q6h Recommended Regimen Carbapenem ▸ Meropenem 1 g IV q8h OR ▸ Imipenem/Cilastatin 500 g IV q6h or 1 g q8h OR ▸ Doripenem 500 g IV q8h Penicillin-based ▸ Piperacillin-Tazobactam 3.375 g IV q6h Recommended Regimen ▸ Vancomycin 1-2 g IV q8h

Initial Empiric Treatment of Biliary Infection in Adults

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Community-acquired acute cholecystitis of mild-to-moderate severity   ▸  Recommended Regimen Community-acquired acute cholecystitis of severe physiologic disturbance, advanced age, or immunocompromised state   ▸  Recommended Regimen Acute cholangitis following bilio-enteric anastamosis of any severity   ▸  Recommended Regimen Health care–associated biliary infection of any severity   ▸  Recommended Regimen

Recommended Regimen ▸ Cefazolin 1-2 g IV q8h OR ▸ Cefuroxime 1.5 g IV q8h OR ▸ Ceftriaxone 1-2 g IV q12-24h Recommended Regimen ▸ Meropenem 1 g IV q8h OR ▸ Imipenem/Cilastatin 500 g IV q6h or 1 g q8h OR ▸ Doripenem 500 g IV q8h OR ▸ Piperacillin-Tazobactam 3.375 g IV q6h OR ▸ Ciprofloxacin 400 g IV q12h OR ▸ Levofloxacin 750 mg IV q24h OR ▸ Cefepime 2 g IV q8-12h PLUS ▸ Metronidazole 500 mg IV q8-12h or 1.5 g q24h Recommended Regimen ▸ Meropenem 1 g IV q8h OR ▸ Imipenem/Cilastatin 500 g IV q6h or 1 g q8h OR ▸ Doripenem 500 g IV q8h OR ▸ Piperacillin-Tazobactam 3.375 g IV q6h OR ▸ Ciprofloxacin 400 g IV q12h OR ▸ Levofloxacin 750 mg IV q24h OR ▸ Cefepime 2 g IV q8-12h PLUS ▸ Metronidazole 500 mg IV q8-12h or 1.5 g q24h Recommended Regimen ▸ Meropenem 1 g IV q8h OR ▸ Imipenem/Cilastatin 500 g IV q6h or 1 g q8h OR ▸ Doripenem 500 g IV q8h OR ▸ Piperacillin-Tazobactam 3.375 g IV q6h OR ▸ Ciprofloxacin 400 g IV q12h OR ▸ Levofloxacin 750 mg IV q24h OR ▸ Cefepime 2 g IV q8-12h PLUS ▸ Metronidazole 500 mg IV q8-12h or 1.5 g q24h PLUS ▸ Vancomycin 1-2 g IV q8h