Antimicrobial Approach To Intra-Abdominal Infections in Adults - UpToDate
Antimicrobial Approach To Intra-Abdominal Infections in Adults - UpToDate
Antimicrobial Approach To Intra-Abdominal Infections in Adults - UpToDate
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INTRODUCTION
Spontaneous peritonitis and peritonitis associated with peritoneal dialysis are also
discussed elsewhere. (See "Spontaneous bacterial peritonitis in adults: Treatment and
prophylaxis" and "Microbiology and therapy of peritonitis in peritoneal dialysis".)
MICROBIOLOGY
Intra-abdominal infections usually arise after a breach in the intrinsic mucosal defense
barrier that allows normal bowel flora to inoculate the abdominal cavity. The precise
microbiological spectrum depends on the precise gastrointestinal source (ie, small versus
large bowel).
Perforation of the proximal bowel, as with perforated peptic ulcer, results in an infection
that is microbiologically distinct, reflecting the flora of the upper gastrointestinal tract. The
predominant microbial species in such cases often include aerobic and anaerobic gram-
positive bacteria or Candida spp. (See "Overview of complications of peptic ulcer disease",
section on 'Perforation'.)
Prior antimicrobial therapy and health care exposures are associated with microbiologic
changes in the bowel flora, and intra-abdominal infections in such settings are thus more
likely to involve nosocomial pathogens, such as Pseudomonas aeruginosa and other drug-
resistant organisms. Enterococci are most likely to be clinically relevant in health care-
associated infections, particularly postoperative infections, in contrast to community-
acquired infections, in which they are frequently isolated but are often not important
pathogens [9,10]. Candida spp are also more common, in both small and large bowel
processes, among patients with hospital-acquired infection, prior antibiotic exposure,
immunocompromising conditions, or with recurrent infection [11]. (See 'Considerations
for specific pathogens' below.)
Timing — Patients who are critically ill should receive empiric antimicrobial therapy as
soon as possible, ideally once blood and urine samples have been obtained for culture. In
patients who are not critically ill, delaying antibiotic therapy until samples from the site of
abdominal infection have been obtained for culture can be helpful to optimize the
microbiologic yield that guides subsequent antibiotic selection.
● Whether there are individual risk factors for infection with resistant bacteria (such as
recent travel to areas of the world that have high rates of antibiotic-resistant
organisms or known colonization with such organisms).
● Whether the patient is considered to be at high risk for adverse outcomes. High-risk
features that are associated with poor outcomes after intra-abdominal infection are
advanced age (>70 years), delay in initial intervention >24 hours, inability to achieve
adequate debridement or control of infection with drainage, other comorbidity (eg,
renal or liver disease, malignancy), immunocompromising condition (eg, poorly
controlled diabetes mellitus, chronic high-dose corticosteroid use, use of other
immunosuppressive agents, neutropenia, advanced HIV infection, B or T lymphocyte
defects), organ dysfunction, severe peritoneal involvement or diffuse peritonitis, low
albumin level, and poor nutritional status [11,14-16].
Patients with community-acquired infections of mild to moderate severity who have none
of these risk factors may not warrant very broad coverage, as the likelihood of resistant
bacteria is low and the consequences of not covering them empirically are less. In
contrast, broad coverage is appropriate in patients who are at risk for infection with
resistant bacteria or who are at risk for adverse outcomes and mortality should empiric
antibiotic therapy not be adequate. Thus, regimen selection is somewhat different for
these different populations. (See 'Low-risk community-acquired infections' below and
'High-risk community-acquired infections' below and 'Health care-associated infections'
below.)
Other factors that influence the choice of regimen include the location or type of infection
(ie, gram-negative anaerobes are generally not critical pathogens in infections arising
from the upper gastrointestinal tract), whether there is a plan for surgical intervention,
the local rates of antibiotic-resistant Enterobacteriaceae, and expected patient tolerance.
Rates of antibiotic resistance in Enterobacteriaceae are high in certain parts of the world,
including east Asia, Africa, and the Middle East, and are especially high in southeast Asia
[17]. Travelers from these areas are at risk for colonization with resistant bacteria; this risk
generally lasts a few weeks but can be prolonged in those with diarrhea or antibiotic
exposure during travel [17-20].
Overarching these considerations are goals for antibiotic stewardship, which generally
favor narrower rather than broader coverage when possible.
The suggested regimens in the following sections are intended to provide general
guidance and may need to be altered to cover emerging resistance patterns that are
specific to the hospital or region; this is more likely to be necessary for the aerobic
component but could also apply to the anaerobic component.
These recommendations are also generally in keeping with the joint Surgical Infection
Society (SIS) and the Infectious Diseases Society of America (IDSA) guidelines on the
management of complicated intra-abdominal infections, which were published in 2010.
The SIS published updated guidelines in 2017, while the IDSA guidelines are in the process
of revision [11,21]. There are some exceptions based on updated in vitro susceptibility
data. As examples, although clindamycin and cefotetan were previously considered
acceptable options for intra-abdominal infections involving anaerobes, these drugs are no
longer recommended due to escalating rates of resistance in the B. fragilis group. As
detailed in those guidelines, ampicillin-sulbactam is also not recommended due to high
rates of resistance among community-acquired E. coli.
For these community-acquired infections, an empiric antimicrobial regimen does not have
to include specific activity against enterococci or Pseudomonas. In several trials, clinical
outcomes for community-acquired intra-abdominal infections have been similar with
empiric regimens that have enterococcal and/or pseudomonal activity and those that do
not [9,22-26].
The SIS/IDSA 2010 guidelines also list cefoxitin, moxifloxacin, and tigecycline as options,
but we generally avoid using these agents in this setting [11]. This is because of
substantial rates of in vitro resistance to cefoxitin and fluoroquinolones among Bacteroides
spp and coliforms [27,28] and concern for increased mortality associated with tigecycline
compared with other antibiotics for various infections, including intra-abdominal
infections [29,30]. (See "Anaerobic bacterial infections", section on 'Antimicrobial
resistance' and "Treatment of hospital-acquired and ventilator-associated pneumonia in
adults", section on 'Other agents'.)
The following initial empiric regimens are appropriate in areas where the local rates of
resistance to these antibiotics are <10 percent:
If the patient cannot tolerate beta-lactams or is at risk for infection with an extended-
spectrum beta-lactamase (ESBL)-producing organism (eg, known colonization or prior
infection with an ESBL-producing organism), a carbapenem (imipenem or meropenem)
should be chosen. The SIS 2017 guidelines also recommend adding vancomycin or
ampicillin for regimens other than imipenem or piperacillin-tazobactam to provide
enterococcal coverage, but we do not routinely employ empiric coverage of Enterococcus
spp for community-acquired infections.
For patients who cannot use beta-lactams or carbapenems (eg, because of severe
reactions), vancomycin plus aztreonam plus metronidazole is an alternative regimen.
For critically ill patients who warrant empiric antifungal therapy, an echinocandin (eg,
anidulafungin, caspofungin, micafungin) is appropriate. (See "Management of candidemia
and invasive candidiasis in adults".)
When beta-lactams or carbapenems are chosen for patients who are critically ill or are at
high risk of infection with drug-resistant pathogens, we favor a prolonged infusion dosing
strategy, which is also endorsed by the World Society of Emergency Surgery (WSES) [31].
(See "Prolonged infusions of beta-lactam antibiotics".)
Additions or modifications to the regimen may be indicated if other risk factors are
present:
● For patients with health care-associated intra-abdominal infection who are known to
be colonized with MRSA or who are at risk of having an infection due to this
organism because of prior treatment failure and significant antibiotic exposure,
empiric antimicrobial coverage directed against MRSA, typically with vancomycin,
should be provided. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in
adults: Treatment of bacteremia".)
● For patients who are known to be colonized with highly resistant gram-negative
bacteria, the addition of an aminoglycoside, polymyxin, or novel beta-lactam
combination (ceftolozane-tazobactam or ceftazidime-avibactam) to an empiric
regimen may be warranted. These agents should be combined with an agent that
has activity against anaerobes (eg, metronidazole). (See "Principles of antimicrobial
therapy of Pseudomonas aeruginosa infections", section on 'Management of
multidrug-resistant organisms' and "Acinetobacter infection: Treatment and
prevention", section on 'Second-line antibiotics' and "Carbapenem-resistant E. coli, K.
pneumoniae, and other Enterobacterales (CRE)", section on 'Approach to treatment'.)
● Empiric antifungal coverage is appropriate for patients at risk for infection with
Candida spp, including those with upper gastrointestinal perforations, recurrent
bowel perforations, surgically treated pancreatitis, heavy colonization with Candida
spp, and/or yeast identified on Gram stain of samples from infected peritoneal fluid
or tissue [21]. Fluconazole can be used for patients who are not severely ill and have
no history of infection with a fluconazole-resistant isolate; otherwise, an
echinocandin can be used. (See "Management of candidemia and invasive
candidiasis in adults".)
Assessment of culture data — The source and timing of collection of culture material
are critical to the utility of culture results in guiding selection of antibiotics. Specifically,
culture of a specimen that is collected prior to starting antibiotics, from a site that should
be sterile, is the most informative. In the critically ill patient who requires antibiotic
treatment prior to collection of cultures from the site of infection, cultures that are
collected early in the course (eg, within a few hours of antibiotic initiation) are more
meaningful than those that are collected after longer periods of antibiotic exposure.
Culture of a specimen collected days after starting antibiotics, especially if collected from a
chronic drain, is more likely to reflect colonizing bacteria that may have developed
resistance to the treatment regimen but are not necessarily causing infection in the
patient. For this reason, it is advisable to avoid collecting cultures from chronic
drains/fistulae, and results of all such cultures should be assessed carefully for clinical
relevance before decisions are made to target results of these cultures with antibiotic
therapy [11].
Antibiotic stewardship — In the interests of preserving antibiotic efficacy over time for
individual patients and populations, narrowing of antibiotics is advisable once a patient
has improved and/or results of reliable cultures are available. Lower-risk patients with
community-acquired intra-abdominal infection likely do not warrant alteration of therapy
if a satisfactory clinical response to source control and initial therapy occurs, even if
unsuspected and untreated pathogens are later reported [11].
Susceptibility of anaerobic pathogens is rarely known at the time that a decision about the
appropriate antibiotic regimen is made since results take a long time, laboratory methods
for isolating anaerobes are not well standardized, and activity is usually predictable based
on in vitro susceptibility testing from reference laboratories [35], clinical trials, and the site
of infection [8,36].
Parenteral versus oral therapy — For patients who are able to eat and tolerate oral
medications and whose relevant organisms are not resistant to oral agents, an
intravenous regimen can be transitioned to an oral regimen once the patient has
demonstrated clinical improvement. Reasonable oral regimens that cover common gut
aerobic and anaerobic bacteria include levofloxacin (750 mg once daily) or ciprofloxacin
(500 mg twice daily), each with metronidazole (500 mg three times daily), or monotherapy
with amoxicillin-clavulanate (875/125 mg two to three times daily), depending on
susceptibility testing.
In patients who present clinically with a syndrome more typical of an abscess caused
by gram-negative organisms and anaerobes (acute presentation, fevers, septic
physiology), the isolation of actinomyces on culture of the infected site is of
uncertain clinical significance. In such cases, we generally include an antibiotic that is
active against actinomyces in the regimen (eg, penicillins) and continue for one to
two months, longer than the duration typically warranted for intra-abdominal
infections. We also monitor closely for symptoms suggestive of classic actinomycosis
with a low threshold for repeat imaging if there is concern for recrudescent infection
following antibiotic discontinuation.
Infectious disease consultation — Consultation with an expert in infectious diseases
can be especially helpful in the setting of diagnostic uncertainty, for assessment of culture
results to guide narrowing of empiric antibiotics, and in specific complex situations. These
include neutropenic, organ transplant, or otherwise-immunocompromised patients and
patients with antibiotic allergies, potentially infected foreign material (eg, mesh), intra-
abdominal malignancy, inflammatory bowel disease, fistulae, or morbid obesity.
When adequate source control has been achieved and the contaminated material cleared
from the intra-abdominal space, we generally limit antimicrobial therapy to four to five
days [11]. The efficacy of such a short course of antimicrobial therapy was demonstrated
in the Study To Optimize Peritoneal Infection Therapy (STOP-IT) trial, in which 518 patients
with complicated intra-abdominal infection and adequate source control were randomly
assigned to receive either a fixed course of antibiotics for 4±1 days (experimental group)
or antibiotics until two days after resolution of fever, leukocytosis, and ileus, with a
maximum of 10 days of antimicrobial therapy (control group) [39]. The median duration of
antibiotics was four days in the experimental group versus eight days in the control
group. The composite primary outcome of surgical site infection, recurrent intra-
abdominal infection, or death occurred in a similar percentage of patients in both groups
(21.8 in the experimental group versus 22.3 percent in the control group). No significant
between-group differences were observed in the individual rates of the components of
the primary outcome. Similarly, in a trial of critically ill patients with postoperative intra-
abdominal infections and adequate source control, the 45-day mortality rate was not
different with a short versus longer antibiotic course (8 versus 15 days) [40].
However, there are several situations in which a longer course of antibiotic therapy is
appropriate.
● For patients in whom source control is known to be suboptimal, the optimal duration
of antibiotic treatment is uncertain and decisions on treatment duration must be
made on a case-by-case basis.
● For those patients with uncomplicated appendicitis who do not undergo immediate
surgery, we generally continue antibiotic therapy for approximately 10 days, as in
several trials which suggested the safety of this approach in select patients [41]. (See
'Source control and drainage' above.)
● In some cases, an indwelling catheter is required for ongoing drainage and removal
of infected material. We generally continue antibiotics in such cases until the efficacy
of catheter drainage is established, for example, until an infected hematoma is
liquefied well enough to drain effectively via catheter. This may require two to three
weeks for a peritoneal abscess. Liver abscess is typically treated for four to six weeks
(see "Pyogenic liver abscess", section on 'Treatment'). If there is chronic active
drainage through the catheter from an ongoing bowel or biliary leak without
accumulation in the peritoneal cavity, discontinuation of antibiotics is usually
reasonable as long as the patient has clinically improved.
Patients with undrained abscesses, uncontrolled ongoing bowel leak, or other unresolved
mechanical problems often develop worsening clinical signs and symptoms of infection
after antibiotics are stopped. We generally refer such patients for repeat surgical or
percutaneous intervention for source control. For patients in whom source control cannot
be achieved, long-term antibiotics are unlikely to be helpful.
Several studies have evaluated the utility of inflammatory markers to assist in guiding
antibiotic discontinuation, but most of these have been performed with procalcitonin,
which is not widely available. In one study of patients with secondary peritonitis who
underwent emergency surgery, antibiotic discontinuation based on procalcitonin
thresholds (level <1.0 ng/mL or >80 percent decrease compared with the first
postoperative day), in addition to resolution of clinical signs, was associated with a shorter
duration of antibiotic use and similar adverse events compared with historical controls
[42]. In a separate retrospective study, procalcitonin guidance was associated with a 50
percent reduction in antibiotic duration (5 versus 10 days) among intensive care unit
patients with secondary peritonitis (both with and without septic shock) [43]. However, in
another study of patients with perioperative septic shock in the setting of intra-abdominal
infections, the rate and degree of procalcitonin decrease failed to accurately predict
treatment response [44].
Patients, particularly those with uncertain source control, should be assessed clinically
during antibiotic therapy and after discontinuation for treatment failure, which is
suggested by persistent or recurrent signs and/or symptoms of infection, including fever,
hypotension, nausea, abdominal pain, organ dysfunction, or leukocytosis. In such cases,
the possibility of inadequate source control (eg, an undrained abscess, active bowel leak,
retained infected mesh) should be assessed with repeat imaging. The original
microbiologic data and the antibiotic regimen should also be reviewed to ensure that the
clinically relevant pathogens have been appropriately covered. As noted, most clinical
treatment failures are due to failure to achieve source control; cultures from chronic
drains, surface wounds, or other nonsterile sites cannot be relied upon to identify
organisms requiring targeted antibiotics.
Other considerations in patients with ongoing infectious symptoms or signs include other
nosocomial infections (eg, Clostridioides [formerly Clostridium] difficile colitis, health care-
associated pneumonia or urinary tract infection, or catheter-associated bloodstream
infection). For patients with persistent clinical symptoms and signs but in whom no
evidence of a new or persistent infection is uncovered after a careful investigation,
discontinuation of antimicrobial therapy is warranted [11]. Noninfectious processes such
as thromboembolic disease, drug reaction, and pancreatitis are potential mimickers of
infection.
● Antibiotic therapy
Cultures from a chronic indwelling drain more likely reflect colonizing bacteria
rather than clinically relevant pathogens. (See 'General principles of regimen
selection' above.)
• Duration of antibiotic therapy – For patients who have adequate source control,
we suggest limiting antibiotic therapy to four to five days (Grade 2B). Longer
courses are often appropriate if source control is suboptimal or uncertain. (See
'Duration of therapy' above.)
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25. Malangoni MA, Song J, Herrington J, et al. Randomized controlled trial of moxifloxacin
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Topic 101694 Version 27.0
GRAPHICS
Bacteriology
Aerobes 1256
Klebsiella 119
Enterococcus 277
Anaerobes 1187
Peptostreptococcus 220
Fusobacterium 35
Miscellaneous 116
¶ Numbers of isolates are greater than numbers of cases since the majority of cases had more
than one microorganism isolated.
Dose
Single-agent regimen
or
or
or
or
or
Plus:
The antibiotic doses listed are for adult patients with normal renal function. The duration of
antibiotic therapy depends on the specific infection and whether the presumptive source of
infection has been controlled; refer to other UpToDate content for details.
¶ For most uncomplicated biliary infections of mild to moderate severity, the addition of
metronidazole is not necessary.
Dose
Single-agent regimen
OR
PLUS:
Local rates of resistance should inform antibiotic selection (ie, agents for which there is >10%
resistance among Enterobacteriaceae should be avoided). If the patient is at risk for infection
with an extended-spectrum beta-lactamase (ESBL)-producing organism (eg, known
colonization or prior infection with an ESBL-producing organism), a carbapenem should be
chosen. When beta-lactams or carbapenems are chosen for patients who are critically ill or are
at high risk of infection with drug-resistant pathogens, we favor a prolonged infusion dosing
strategy. Refer to other UpToDate content on prolonged infusions of beta-lactam antibiotics.
The antibiotic doses listed are for adult patients with normal renal function. The duration of
antibiotic therapy depends on the specific infection and whether the presumptive source of
infection has been controlled; refer to other UpToDate content for details.
IV: intravenous.
Dose
Single-agent regimen
Combination regimen
OR
PLUS:
OR
When beta-lactams or carbapenems are chosen for patients who are critically ill or are at high
risk of infection with drug-resistant pathogens, we favor a prolonged infusion dosing strategy.
Refer to other UpToDate content on prolonged infusions of beta-lactam antibiotics.
The antibiotic doses listed are for adult patients with normal kidney function. The duration of
antibiotic therapy depends on the specific infection and whether the presumptive source of
infection has been controlled; refer to other UpToDate content for details.
IV: intravenous.
Travel to areas with higher rates of antibiotic-resistant organisms* within the few weeks
prior to infection onset or if antibiotics were received during travel
* High rates of antibiotic resistance have been reported from southeast Asia, east Asia, the
Middle East, and Africa.
References:
1. Solomkin JS, Mazuski JE, Bradley JS, et al. 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. Clin Infect Dis 2010; 50:133.
2. Woerther PL, Burdet C, Chachaty E, Andremont A. Trends in human fecal carriage of extended-spectrum
β-lactamases in the community: toward the globalization of CTX-M. Clin Microbiol Rev 2013; 26:744.
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