Intra-Abdominal Infections Flashcards
(76 cards)
1
Q
Intra-abdominal infection
A
infection within the peritoneal cavity (or retroperitoneal cavity)
2
Q
Peritoneal cavity contains
A
- Stomach, jejunum, ileum, colon
- Appendix
- Liver
- Gallbladder
- Spleen
3
Q
Retroperitoneal space contains
A
- Duodenum
- Pancreas
- Kidneys
4
Q
Primary Peritonitis
A
infection of the peritoneal cavity without an evident source in the abdomen
5
Q
Primary peritonitis develops in
A
- Peritoneal dialysis
- Patients with alcoholic cirrhosis (liver disease)
6
Q
Primary peritonitis may develop as a result of?
A
Ascites or abnormal accumulation of abdominal fluids
7
Q
Signs and symptoms of primary peritonitis
A
- N&V
- Fever
- Abdominal tenderness
- Abdominal distension
- Hypotension
- Cloudy dialysate fluid
8
Q
Secondary Peritonitis
A
disease process that originates within the abdomen
9
Q
Secondary peritonitis diseases from abdomen
A
- Diverticulitis
- Cholecystitis
- Ulceration, Ischemia, or Obstruction
- Appendicitis
- Blunt / Penetrating Trauma -Operative Contamination of Peritoneum
- Female Genital Tract (Post-Operative Uterine Infection or Endometritis)
10
Q
What is secondary peritonitis usually caused by?
A
polymicrobial infections
11
Q
Is surgery necessary in primary or secondary peritonitis?
A
secondary peritonitis
12
Q
What is the most common cause of secondary peritonitis?
A
appendicitis
13
Q
Appendicitis usually occurs in which part of life?
A
second or third decade of life
14
Q
Appendicitis presentation occurs as
A
- Early symptoms
- Later symptoms
- Perforation
15
Q
Appendicitis early symptoms
A
Dull, Non-Localized Right Lower Quadrant (RLQ) pain, bowel irregularity, and flatulence
16
Q
Appendicitis later symptoms
A
Pain / Tenderness, more localized pain, nausea and vomiting
17
Q
Appendicitis perforation likely if patient presents with?
A
- Temperature greater than 103 °F
- Leukocytes > 15,000 cells / mm3
18
Q
Signs and symptoms of secondary peritonitis
A
- Nausea & Vomiting
- Fever
- Abdominal Tenderness
- Abdominal distension
- Hypotension
19
Q
Secondary peritonitis complications
A
- Abscesses (or Abscesses)
- Intraperitoneal Adhesions
- Gangrene Bowel
- Septic Shock
20
Q
Primary Peritonitis is often caused by a single organism that gets introduced by:
A
- Catheter OR
- Translocation from the bloodstream (Hematogenous) OR
- Translocation from the Lymphatic System
21
Q
Primary Peritonitis Cirrhotic Ascites can be caused by which organisms
A
- Gram-negative
- Gram-positive
22
Q
Primary Peritonitis Cirrhotic Ascites Gram-Negative Organisms?
A
- Escherichia coli
- Klebsiella pneumoniae
23
Q
Primary Peritonitis Cirrhotic Ascites Gram-Positive Organisms?
A
- Streptococcus pneumoniae
- Viridians streptococcus
24
Q
Primary Peritonitis Peritoneal Dialysis can be caused by which organisms
A
- Gram-negative
- Gram-positive
25
Primary Peritonitis Peritoneal Dialysis Gram-Positive organisms?
- Coagulase-Negative Staphylococci (CoNS)
- Staphylococcus aureus
- Streptococci
26
Primary Peritonitis Peritoneal Dialysis Gram-Negative organisms?
- Escherichia coli
| - Pseudomonas aeruginosa
27
For primary peritonitis in cirrhotic ascites, which organism is most common pathogen?
Gram-negative organisms
28
For primary peritonitis in peritoneal dialysis, which organism is most common pathogen?
Gram-positive organisms
29
For primary peritonitis in peritoneal dialysis, gram negative organisms are associated with increased?
mortality
30
Secondary Peritonitis Common Pathogens in Community-Acquired Infections
- Gram-negative
- Gram-positive
- Anaerobes
31
Secondary Peritonitis Gram negative causative pathogens
- E.coli
- Klebsiella species
- Proteus species
32
Secondary Peritonitis Gram positive causative pathogens
- Streptococcus species
- Enterococcus species
- Staphylococcus aureus
33
Secondary Peritonitis anaerobe causative pathogens
- Bacteroides species
- Peptostreptococcus species
- Clostridium species
34
Which of the following agents is likely to have activity against B. fragilis?
```
A. Levofloxacin
B. Metronidazole
C. Ceftriaxone
D. Amoxicillin
E. Gentamicin
```
B. Metronidazole
35
Primary Peritonitis Treatment in Cirrhosis
- Cefotaxime, 2 grams IV, q8h for 5–10 days, depending on response
- Ceftriaxone, 2 grams IV, q24h for 5–10 days, depending on response
36
When is primary peritonitis prophylaxis therapy needed?
For patients who have had more than 1 episode of Spontaneous Bacterial
Peritonitis (SBP)
37
primary peritonitis prophylaxis therapy
- Bactrim® double-strength (DS) daily for 5 days per week
| - Ciprofloxacin (Cipro®), 750 mg weekly (or 500 mg daily)
38
Primary Peritonitis Treatment in Peritoneal Dialysis
- Vancomycin + Cefepime for 14 – 21 days
| - Vancomycin + Ceftazidime for 14 – 21 days
39
Secondary Peritonitis Treatment Goals
- Correction of the Disease Processes or Injuries
- Surgical Intervention for Source Control and Drainage of Abscess (or Abscesses)
- Fluid Resuscitation within 6 hours
- Empiric Antibiotics (Abx) – Administer once suspected in the ED!
40
Secondary Peritonitis Mild-to-Moderate Infection
- APACHE II Score < 15
- Perforated or Abscessed Appendicitis
- Acute Diverticulitis
41
Secondary Peritonitis Severe Infection
- APACHE II Score of 15 or more
- Advanced Age
- Immunocompromised Patient
- Nosocomial Infections (e.g., Post-Operative Infections)
42
For Secondary Peritonitis Community-Acquired Mild-to-Moderate Infections,
Empiric Antibiotics should be active against:
- Enteric Gram-Negative Bacilli
- Enteric Gram-Positive Streptococci
- Anaerobes
43
Secondary Peritonitis Community-Acquired Mild-to-Moderate Infection Single Agent Regimen
Cefoxitin, Ertapenem or Moxifloxacin
44
Secondary Peritonitis Community-Acquired Mild-to-Moderate Infection Combination Therapy
- Cefazolin
- Cefuroxime
- Ceftriaxone
- Ciprofloxacin
- Levofloxacin in combination with Metronidazole
45
Community-Acquired Mild-to-Moderate Infections NOT Recommended Agents
- Empiric Ampicillin with Sulbactam (Unasyn®) due to E. coli resistance
- Cefotetan or Clindamycin (B. fragilis resistance)
- Aminoglycosides (less toxic agents are available)
- Empiric coverage of Pseudomonas, Enterococcus, MRSA, or Candida
46
Which of the following agents has activity against P. aeruginosa?
a. Moxifloxacin
b. Ceftriaxone
c. Ertapenem
d. Cefepime
e. Ampicillin with Sulbactam
d. Cefepime
47
Secondary Peritonits Community-Acquired Severe Infections Empiric Antibiotics should be active against?
- Enteric Gram-Negative Bacilli
- Enteric Gram-Positive Streptococcus
- Anaerobes
- Pseudomonas aeruginosa
48
Secondary Peritonits Community-Acquired Severe Infections Single Agent Regimen
Imipenem with Cilastatin (Primaxin®), Meropenem,
| Doripenem, OR Piperacillin with Tazobactam (Zosyn®)
49
Secondary Peritonits Community-Acquired Severe Infections Combination Therapy
- Cefepime
- Ceftazidime
- Ciprofloxacin
- Levofloxacin in combination with Metronidazole
50
Cefoxitin Dose
2 g IV q6h
51
Ertapenem Dose
1 g IV q24h
52
Moxifloxacin Dose
400 mg IV / PO q24h
53
Cefazolin Dose
2 g IV q8h
54
Ceftriaxone Dose
2 g IV q24h
55
Ciprofloxacin Dose
- 400 mg IV, q12h
| - 400 mg IV, q8h
56
Levofloxacin Dose
750 mg IV, q24h
57
Cefepime Dose
2 g IV, q8h
58
Imipenem w/ Cili Dose
1 g IV, q8h
59
Meropenem Dose
1 g IV, q8h
60
Metronidazole Dose
500 mg IV, q8h
61
Severe / Nosocomial Infections Empiric MRSA coverage is required in the following cases
- Patient site of infection is colonized with MRSA
- Patient has invasive device inserted at admission
- Surgical history
- Dialysis
- Residence in long-term care facility in the last 12 months
62
Severe / Nosocomial Infections Empiric MRSA coverage therapy
Vancomycin, 15 mg / kg IV, q8h – q24h
63
Severe / Nosocomial Infections Enterococcus coverage is required in the following cases:
- Post-Operative Infections
- History of Cephalosporin antibiotic use that may select for Enterococcus
- Immunocompromised patients
- Positive cultures
64
Severe / Nosocomial Infections Enterococcus coverage therapy
- Ampicillin, 2 grams IV, q4h
- Piperacillin with Tazobactam, 3.375 g IV q6h
- Vancomycin, 15 mg / kg IV, q8h – q24h
65
Empiric Fungal Coverage is NOT recommended!
| Only use IF culture is positive for Candida AND patient has:
- Recently received immunosuppressive therapy
- Perforation of gastric ulcer on acid suppression
- Perforation due to malignancy
- Had recurrent Intra-Abdominal Infections
66
Empiric Fungal Coverage for Candida therapy
- Fluconazole, 400 mg IV, daily
| - Echinocandins may be used in critically ill patients, or if organism is resistant
67
Severe / Nosocomial Infections Duration of Therapy
Typically 4-7 days, unless difficult to achieve adequate source of infection control
68
Adequate source control of the infection is shown by
Afebrile, normal White Blood Cell Count (WBC), return of bowel function
69
Patient may complete treatment with equivalent PO treatment such as
- Oral Cephalosporin (Cephalexin / Cefixime + Metronidazole)
- Amoxicillin with Clavulanate (Augmentin®)
- Moxifloxacin
- Ciprofloxacin (or Levofloxacin) + Metronidazole
70
```
Surgical Prophylaxis (less than 24 hours) is sufficient for localized
processes, such as
```
- Non-Perforated Appendicitis
- Cholecystitis
- Bowel Obstruction / Infarction
- Traumatic Injury operated on within 12 hours
71
AK is a 16-year-old female admitted to the hospital with abdominal pain, diarrhea, and nausea. She has rebound tenderness of the right lower quadrant (RLQ). Patient was taken to surgery for removal of a ruptured appendix, and given Cefazolin for surgery prophylaxis. Adequate source control was achieved during surgery
Vitals
T 100.1 °F, BP 136 / 92, RR 16, HR 90
What is the likely etiology of AK’s infection?
Disease process originating within the abdomen (Secondary Peritonitis);
Gram-Negative Enterococci and Anaerobes
72
AK is a 16-year-old female admitted to the hospital with abdominal pain, diarrhea, and nausea. She has rebound tenderness of the right lower quadrant (RLQ). Patient was taken to surgery for removal of a ruptured appendix, and given Cefazolin for surgery prophylaxis. Adequate source control was achieved during surgery
Vitals
T 100.1 °F, BP 136 / 92, RR 16, HR 90
What should this patient receive for empiric treatment of her Appendicitis
(include Drug, Dose, Route, Frequency / Interval, and Duration)?
Cefoxitin, 2 g IV, q6h (for mild-to-moderate infection)
73
AK is a 16-year-old female admitted to the hospital with abdominal pain, diarrhea, and nausea. She has rebound tenderness of the right lower quadrant (RLQ). Patient was taken to surgery for removal of a ruptured appendix, and given Cefazolin for surgery prophylaxis. Adequate source control was achieved during surgery
Vitals
T 100.1 °F, BP 136 / 92, RR 16, HR 90
What is the recommended Antimicrobial Treatment Duration for this patient?
```
A.Therapy complete. Patient received intra-operative antibiotics
B. 4–7days
C. 10 days
D. 14 days
E. 21 days
```
B. 4–7days
74
AK improved post-operatively with your recommended antibiotic regimen.
The discharging team received her culture / sensitivity results and had patient complete her 7-day treatment course with PO Cephalexin as an outpatient. 10 days after completing antibiotics, AK develops diffuse pain over the appendectomy surgical site. Abdominal CT reveals a Peritoneal Abscess. The abscess is drained and fluid is sent to the lab
How was this patient managed inappropriately?
Her regimen did NOT include Metronidazole with her cephalosporin for
Anaerobic coverage
75
A 47-year-old male with history of alcoholism presents to the ED with
nausea and vomiting and increased abdominal pain. He is Child-Pugh Class 3 with Ascites. He has no prior history of Peritonitis.
Vitals
T 101.0 °F, BP 100 / 68, RR 18, HR 90
```
Labs
WBC 13.2 x 103 cells / mm3
SCr 0.9 (baseline 0.8)
Ascitic Fluid PMNs – 570 cells / mm3
Culture is negative to date
```
How should this patient be managed?
Cefotaxime, 2g IV, q8h for 10 days
Ceftriaxone, 2 g IV, q24h for 10 days
76
A 47-year-old male with history of alcoholism presents to the ED with
nausea and vomiting and increased abdominal pain. He is Child-Pugh Class 3 with Ascites. He has no prior history of Peritonitis.
Vitals
T 101.0 °F, BP 100 / 68, RR 18, HR 90
```
Labs
WBC 13.2 x 103 cells / mm3
SCr 0.9 (baseline 0.8)
Ascitic Fluid PMNs – 570 cells / mm3
Culture is negative to date
```
5 days after admission, the patient has improved
Vitals: T 37 °C, BP 116 / 82, RR 18, HR 80
Labs: WBC 8.2 x 103 cells / mm3, Ascitic Fluid PMNs < 250 cells / mm3, culture Negative
What do you recommend?
Depending on her response, we would recommend no further therapy
