DS: GI and Intraabdominal Infection

Question 1

Framework of IDSA Intraabdominal IAI guidelines

Answer 1

Question 2

Defining types of intra abdominal infection

Answer 2

Question 3

Health-care associated

Answer 3

Presence of any risk factors:
- invasive device at time of admission
- Hx of MRSA infection or colonization
- Hx of surgery
- Hospitalization
- Dialysis
- Residence in long term care facility in last 12 month

Question 4

Hospital-onset

Answer 4

Positive culture >48 hours of hospital admission

Question 5

Uncomplicated IAI

Answer 5

Affects a single organ only without spread into the peritoneum

Question 6

Complicated IAI

Answer 6

Extension beyond hollow viscus of origin into peritoneal space → peritonitis or abscess formation

Question 7

IAI Specific Pathogens

Answer 7

Note: the further you go down the bugs change and the amount of bug changes

Question 8

Organ infection:

Answer 8

Appendix: Appendicitis
Gall bladder: cholecystitis
Bide duct: cholangitis
Pancreas: pancreatitis
Colon: Diverticulitis

Question 9

Treatment of high risk - Community-acquired complicated appendicitis

Answer 9

Question 10

Patient Management

Answer 10

Fluid/cultures not routinely approved for patient with community acquired infection unless clinicaly toxic or high risk

Question 11

Duration IAI: STOP IT TRIAL

Answer 11

Control group: 8 days; Experimental group: 4 days
Patient population is adult with complicated intra abdominal and adequate source control
Endpoint: surgical site infection, recurrent infection or death within 30 days after source control
Bottom line: Complicated IAI can be treated with 4 days of abx if adequate source control
Post hoc analyses:
Polymicrobial infection do not have worsen outcome than monomicrobial
Inclusion of vancomycin as part of broad spectrum coverage does not improve outcomes in IAI

Question 12

Management of appendicitis with abx only

Answer 12

Appendicitis cannot be treated by just abx
Two recent non-inferiority studies demonstrated that abx alone are inferior to surgery plus abx for acute appendicitis
2020 Update: CODA study: 1552 adults with appendicitis. Abx were non-inferior to laparoscopy appendectomy –> but still fairly new information

for test questions - it’s always no

Question 13

Healthcare-associated complicated IAI - Empiric treatment

Answer 13

Question 14

Other pathogens: Enterococcus

Answer 14

Question 15

Other pathogen: Candida

Answer 15

Question 16

Other pathogen: MRSA

Answer 16

Question 17

New drugs for IAI: Avycaz and Zerbaxa

Answer 17

No activity against enterococcus
No activity against anaerobes
KPC: Ceftolazane/Tazobactam is not active against CRE with KPC beta-lactamase (most common CRE in the USA)
Both of these medications are FDA approved for IAIs

Question 18

New Drugs: Eravacycline

Answer 18

Evaracycline
-Broad spectrum activity (GN, GP, anaerobes) - including CRE and ESBL
-No PsA coverage
-Better tolerability than tigecycline (less nausea and diarrhea)
-FDA indicated for complicated IAI

NOTE: omadacycline not indicated for IAI (good test question)

Question 19

New Drugs: Relebactam

Answer 19

Relabactam:

Class A/C beta-lactamase inhibitor

Used in imipenem-cilastin

Restores activity vs. CRE (Klebsiella) and PsA

FDA approved for cIAI: Tested the addition of relebactam vs. placebo to imipenem-cilastin
Also approved for cUTI

Question 20

Pancreatitis Management

Answer 20

Question 21

SBP Diagnosis and Management

Answer 21

Question 22

SBP Treatment

Answer 22

Question 23

SBP ppx

Answer 23

Question 24

Acute cholangitis

Answer 24

Definition: Biliary obstruction complicated by infection
Presentation: can be severe with jaundice and elevated transaminases
High mortality rates → early broad spectrum abx
Source control → usually ERCP directed internal drainage within 24 hours
Empiric tx: Broad spectrum (GPO and GNO including anaerobes); enterococcus coverage in patients with hepatic disease or severe immunocompromised patient

Question 25

IAI: Diverticulitis

Answer 25

Question 26

IAI: H. Pylori Treatment

Answer 26

All patients tested for positive H. pylori should be treated - increased risk for gastric cancer if untreated - All patients with peptic ulcer disease should be tested for H.pylori - All consider testing in patients taking low-dose aspirin or chronic non steroidal anti-inflammatory therapy to reduce the risk of GI bleed

Question 27

Persistent H.Pylori Treatment

Answer 27

Question 28

IAI: Infectious diarrhea Risk factor

Answer 28

Risk factors: travel to developing countries, close contact with infected person, poor sanitation

Question 29

Infectious diarrhea Etiology

Answer 29

May be food bourne or waterborne International travel Use of abx agents Immunocompromised host Exposure to infected/colonized animals Attendance at childcare facilities Residence in long term care facilities Hospitalization Certain sexual practices

Question 30

Infectious diarrhea approved abx by pathogen

Answer 30

Question 31

Antiparasitic Therapy by pathogen

Answer 31

Question 32

Specific dosing for infectious diarrhea

Answer 32

Question 33

Specific dosing for infectious diarrhea - cont...

Answer 33

Question 34

Shiga Toxin - Producing E.coli

Answer 34

Shiga Toxin-producing E.coli (STEC): Blood Diarrhea: Leading cause of hemolytic uremic syndrome in children and adults Hemolytic uremic syndrome (HUS): hemolytic anemia, thrombocytopenia, AKI DONT” TREAT WITH ABX

Question 35

CDI - Laboratory testing for CDI

Answer 35

GDH (glutamate dehydrogenase) is common antigen of C.difficiles that can detect either the toxigenic or non toxigenic form If positive - should be followed by the PCR test (stool toxine B NAAT) Important to do GDH test and add on stool EIA toxin test Do not perform repeat testing within 7 days during the same episode of diarrhea Do not screen asymptomatic C.difficiles carriage at admission

Question 36

Updated Initial treatment for CDI

Answer 36

Question 37

Recurrent treatment for CDI

Answer 37

Question 38

CDI important note

Answer 38

Important: Do not perform repeat testing within 7 days during the same episode of diarrhea Do not screen for asymptomatic C.difficile carriage at admission No recommendation on probiotic or PPI use Discontinue inciting abx if possible