Intra-Abdominal Infection Guidelines 2010

Intra-Abdominal Infection Guidelines 2010

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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

Clinical Infectious Diseases 2010; 50:133–64

What Are the Appropriate Procedures for Initial Evaluation of Patients with Suspected Intra-abdominal Infection?

• Further diagnostic imaging is unnecessary in patients with obvious signs of diffuse peritonitis and in whom immediate surgical intervention is to be performed. 
• In adult patients not undergoing immediate laparotomy, CT is the imaging modality of choice to determine the presence of an intra-abdominal infection and its source.

When Should Fluid Resuscitation Be Started for Patients with Suspected Intra-abdominal Infection?


When Should Antimicrobial Therapy Be Initiated for Patients with Suspected or Confirmed Intra-abdominal Infection?

• Antimicrobial therapy should be initiated once a patient receives a diagnosis of an intra-abdominal infection or once such an infection is considered likely. 
• For patients with septic shock, antibiotics should be administered as soon as possible.
  For patients without septic shock, antimicrobial therapy should be started in the ED.
  On the basis of this study, sepsis guidelines have recommended that antibiotics be administered within 1 h of recognition of septic shock. 
• In patients without hemodynamic or organ compromises, the Expert Panel members agreed that antibacterials should be administered within 8 h after presentation.

What Are the Proper Procedures for Obtaining Adequate Source Control?

• An appropriate source control procedure to drain infected foci, control ongoing peritoneal contamination by diversion or resection, and restore anatomic and physiological function to the extent feasible is recommended for nearly all patients with intra-abdominal infection.
• Patients with diffuse peritonitis should undergo an emergency surgical procedure as soon as is possible, even if ongoing measures to restore physiologic stability need to be continued during the procedure. 
• Where feasible, percutaneous drainage of abscesses and other well-localized fluid collections is preferable to surgical drainage.

 
What Are Appropriate Antimicrobial Regimens for Patients with Community-Acquired Intra-abdominal Infection of Mild-to-Moderate Severity and High Severity? 
Agents and Regimens that May Be Used for the Initial Empiric Treatment of Extra-biliary Complicated Intra-abdominal Infection

	Community-acquired infection in pediatric patients	Community-acquired infection in adults
Regimen		Mild-to-moderate severity:   perforated or abscessed appendicitis and other infections of mild-to-moderate severity	High risk or severity:  severe physiologic disturbance, advanced age, or immunocompromised state
Single agent	Ertapenem, meropenem, imipenemcilastatin, ticarcillin-clavulanate, and piperacillin-tazobactam	Cefoxitin, ertapenem, moxifloxacin, tigecycline, and ticarcillin-clavulanic acid	Imipenem-cilastatin, meropenem, doripenem, and piperacillin-tazobactam
Combination	Ceftriaxone, cefotaxime, cefepime, or ceftazidime, each in combination with metronidazole; gentamicin or tobramycin, each in combination with metronidazole or clindamycin, and with or without ampicillin	Cefazolin, cefuroxime, ceftriaxone, cefotaxime, ciprofloxacin, or levoflox-acin, each in combination with metronidazole	Cefepime, ceftazidime, ciprofloxacin, or levofloxacin, each in combination with metronidazole

• Ampicillin-sulbactam is not recommended for use because of high rates of resistance to this agent among community-acquired E. coli. 
• Cefotetan and clindamycin are not recommended for use because of increasing prevalence of resistance to these agents among the Bacteroides fragilis group. 
• Because of the availability of less toxic agents demonstrated to be at least equally effective, aminoglycosides are not recommended for routine use in adults with community-acquired intra-abdominal infection.

What Are Appropriate Diagnostic and Antimicrobial Therapeutic Strategies for Acute Cholecystitis and Cholangitis?

• Ultrasonography is the first imaging technique used for suspected acute cholecystitis or cholangitis.
• Patients undergoing cholecystectomy for acute cholecystitis should have antimicrobial therapy discontinued within 24 h unless there is evidence of infection outside the wall of the gallbladder.

How Should Suspected Treatment Failure Be Managed?

• In patients who have persistent or recurrent clinical evidence of intra-abdominal infection after 4–7 days of therapy, appropriate diagnostic investigation should be undertaken. This should include CT or ultrasound imaging. Antimicrobial therapy effective against the organisms initially identified should be continued.

Clinical Factors Predicting Failure of Source Control for Intra-abdominal Infection

• Delay in the initial intervention (>24 h)
• High severity of illness (APACHE II score ≧15)
• Advanced age 
• Comorbidity and degree of organ dysfunction
• Low albumin level
• Poor nutritional status
• Degree of peritoneal involvement or diffuse peritonitis
• Inability to achieve adequate debridement or control of drainage
• Presence of malignancy 

What Are the Key Elements that Should Be Considered in Developing a Local Appendicitis Pathway?