Intra- abdominal infections Flashcards
(17 cards)
Spontaneous bacterial peritonitis (SBP)
patients at high risk and most common bacteria
High risk - hepatic failure and ascites - alcoholic cirrhosis, continuous ambulatory peritoneal dialysis (CAPD)
most commonly monomicrobial
- E. coli***
- strep
- enterococci
- staphylococcus
SBP clinical presentation and diagnosis
Clinical presentation:
▪Abdominal pain
▪Nausea, vomiting, diarrhea
▪Fevers, chills
▪Reduced/absent bowel sounds
▪Altered mental status/encephalopathy
Diagnosis:
▪Signs and symptoms of infection
▪Ascitic fluid analysis
⎻ Low ascitic fluid protein (< 2.5 g/dL)
⎻ Absolute neutrophil count > 250/mm
SBP recommended treatment
Empiric therapy
**Ceftriaxone 1-2 g IV Q24H
Cefepime 1g IV Q8H
Zosyn 3.375 g IV Q6-8H
meropenem 1g IV Q8H
MRSA coverage (Not common with alcoholic cirrhosis related SBP but common with dialysis related)
ADD one of the following
- vancomycin
linezolid 600mg IV/PO Q12H
Daptomycin 6-12mg/kg IV Q24H
Anaerobic coverage?(really only common in secondary)
SBP treatment when to switch to oral
Once patient is clinically stable and culture results are in we can switch to PO therapy
SBP treatment duration
SBP in patients with cirrhosis and ascites - 5-7 days
Secondary prophylaxis: Oral options include TMP/SMX DS PO once daily OR Ciprofloxacin 500mg PO once daily
Peritonitis in patients undergoing CAPD - 14-21 days
may need to remove peritoneal dialysis and transition to hemodialysis
Secondary peritonitis
common pathogens
USUALLY POLYMICROBIAL
Aerobic gram neg: Most common E. Coli
Aerobic gram positive: streptococcus, enterococcus
Anaerobic bacteria: B. fragilis
Fungi: Candida species (not supper common)
Intra abdominal infections secondary peritonitis - source control examples
repair perforation - if needed with surgery
pesection of infected oragans/tissue
removal of foreign material - if needed with surgery
drain purulent collection - placement of drain
Secondary peritonitis signs and symptoms and diagnostic
Abdominal pain
N/V
fever, chills
loss of appetite
Signs and symptoms paired with imaging (CT scan or X ray)
Secondary peritonitis - considerations for empiric antibiotic therapy
1.Super important to look at susceptibility rates and resistance
for susceptibility want an agent thats at least 85-90% coverage
and want resistance to be 10-20%
- consider if enterococci coverage is needed
- recommended for high severity, history of cephalosporin use, immunocompromised, biliary source of infection, history of valvular heart disease, and/ or prosthetic intravascular material - Consider if anti-fungal coverage is needed
- not really used for empiric but can add if culture shows it is present
Community-acquired (symptoms less than 48 hours of admission)
Mild-moderate severity
empiric regimen
Ceftriaxone 1-2 g IV Q24H + Metronidazole 500 mg IV/PO Q8-12H
Cefazolin 2 g IV Q8H + Metronidazole 500 mg IV/PO Q8-12H
Cefoxitin 2 g IV Q6H
Ertapenem 1 g IV Q24H
Tigecycline 50 mg IV Q12h
Community-acquired
High severity
and
Healthcare-associated
empiric therapy
Piperacillin/tazobactam 3.375-4.5 g IV Q6H - covers enterococci
Meropenem 1 g IV Q8H - covers enterococci
Cefepime 1-2 g IV Q8H + Metronidazole 500 mg IV/PO Q8-12H - does not cover enterococci and would need coverage like vancomycin
Candida albicans on culture
treatment
Fluconazole 200-400 mg IV/PO Q24H
Candida species other than
Candida albicans on culture
Micafungin 100 mg IV Q24H
Intra-abdominal Infections – Oral Antibiotic Regimens Pathogen directed regimen
NOTE: because anaerobes are very hard to treat so no matter what the patients cultures show its important to always add anaerobic coverage (metronidazole)
▪Amoxicillin/clavulanate 875/125 mg PO Q8-12H
▪Cefpodoxime 400 mg PO Q12H + Metronidazole 500 mg PO Q8-12H
▪Cephalexin 1000 mg PO Q6H + Metronidazole 500 mg PO Q8-12H
▪Cefadroxil 1000 mg PO Q12H + Metronidazole 500 mg PO Q8-12H
▪Ciprofloxacin 500-750 mg PO Q12H + Metronidazole 500 mg PO Q8-12H
▪Levofloxacin 750 mg PO Q24H + Metronidazole 500 mg PO Q8-12H
▪TMP/SMX DS 1-2 tabs PO Q12H + Metronidazole 500 mg PO Q8-12H
treatment duration
for general treatment, diverticulitis, appendicitis without preforation, abscess, or peritonitis, Cholecysitits without perforation, bowl injuries repaired within 12 hours
Typically based on if source control was completed and successfully removed from patient if it is not
General treatment duration:
4-7 days after source control
Diverticulitis:
Uncomplicated – antibiotic not needed
Moderate/severe – 5-10 days
If patient has infection and goes to surgery and achieve source control within 24 hours only need a day of therapy (the ones below):
Appendicitis without
perforation, abscess, or
peritonitis:
24 hours
Cholecystitis without
perforation:
24 hours
Bowel injuries repaired within
12 hours:
24 hours
JS is a 29-year-old male who presents to emergency department for a 2-day onset of
severe abdominal pain, loss of appetite, and fever (101.6 F)
▪No pertinent past medical history and no known drug allergies
Pertinent lab values
▪WBC 20,600 cells/mL
▪Hgb 14.5 g/dL
▪Plt 325,000/mm3
▪Na 139 mmol/L
▪K 4.2 mmol/L
▪Cl 103 mmol/L
▪CO2 22 mmol/L
▪BUN 11 mg/dL
▪SCr 1.11 mg/dL (baseline 0.5 mg/dL)
Vitals
▪Temp – 102.2 F
▪HR – 121 bpm
▪RR – 29 bpm
▪BP – 90/60 mmHg (MAP 70 mmHg)
▪Diagnosis
▪Appendicitis with perforation and early abscess formation, concern for peritonitis
How would you classify JS’s IAI?
Complicated, community acquired IAI, high severity
Complicated/ high severity due to high temp, RR, HR, and possible AKI
JB - what could be possible emperic therapy for
complicated community acquired IAI, high severity
Zosyn IV
meropenem
Cefepime + metronidazole
although cipro + metronidazole used to be a popular choice its important to educate physician that local resistance to this treatment is increasing and should no longer be a first choice
