30 - Intra-abdominal Infections Flashcards
What SITES have ANAEROBES?
Bacteriodes / Clostridium / Peptostreptococcus
Intra-Abdominal Infections
Anaerobes
Bacteriodes / Clostridium / Peptostreptococcus
Proximal + Distal Small Intestine
COLON
no anaerobes in BILIARY TRACT or STOMACH
What BACTERIA is found in the STOMACH?
+STREPTOCOCCUS+
covered by most gram + antibiotics
+
+ LACTOBACILLUS +
Gastric Acid = barrier to infection
What BACTERIA is found in the BILIARY TRACT?
- *Typically STERILE**
- *Enterics_ (E.Coli + Kleb) + _Enterococcus**
- NO ANAEROBES*
What BACTERIA is found in the:
COLON?
-ENTERICS-
E.Coli + Kleb
Peptostreptococcus** + **Clostridium
ANAEROBES
Candida
Fungi
What Bacteria are considered:
GI ANAEROBES?
+
ABX TREATMENT
Bacteroides - Clostridium - PeptoStreptococcus
Treated with:
- *Carbapenems** - Metronidazole
- *PIP/TAZO**
Treatment for:
ENTEROBACTERIACEAE
E. Coli + Kleb
CEFTRIAXONE** or **CEFEPIME
PIP-TAZO
no fluoroquinolones or Ampicillin / sulbactam
RESISTANCE
Treatment for:
PSEUDOMONAS
Psuedomonas = Gram Negative –> common in HOSPITAL
Cefepime
PIP/TAZO
- *CARBAPENEMS**
- EXCEPT ERTAPENEM*, usually reserved for ESBL
Treatment for:
+Enterococcus Facium+
FAECIUM = most are VANC RESISTANT = VRE
LINEZLOLID** / **DAPOMYCIN
Treatment for:
+Enterococcus Faecalis+
Gram + Coverage for Enterococcus
Ampicillin** / **Ampicillin-Sulbactam
Imipenem
VANCOMYCIN
LINEZLOLID** / **DAPOMYCIN
PIP-TAZO
ETIOLOGY + BACTERIA
Spontaneous Bacterial Peritonitis = SBP
AKA - PRIMARY Peritonitis (no specific source)
Most Commonly in patients with:
LIVER FAILURE + PPI Use
Typically MONOMicrobial:
- *Streptococcus_ + _Enterics**
- no anaerobes, may even be culture NEGative*
Presentation / Diagnosis
Spontaneous Bacterial Peritonitis = SBP
- *PARACENTESIS**
- *ascitic fluid: PMN>250** cells/mm3
Protein < 1g/dl
suggests primary peritonitis (SBP)
Symptoms:
Fever / ab distention,pain / altered mental status (ECP)
NV / Hypovolemic hypotention
Spontaneous Bacterial Peritonitis = SBP
TREATMENT
- *Streptococcus** + Enterics (E.Coli + Kleb)
- no anaerobes*
CEFTRIAXONE** or **Cefotaxime
for the ENTERICs, strep is covered by most
5 DAYS
should have improvement within 24-48 hours
PROPHYLAXIS
typically for MOST SBP (until no longer in LIVER FAILURE)
FQs or BACTRIM
ABSCESSES
Diagnosis / Etiology
Diagnosed via imaging:
CT** or **ULTRASOUND
Polymicrobial
similar pathogens to 2ndary Peritonitis (CIAI):
Enterics + Anaerobes
Pseudomonas - if HIGH-severity or Healthcare-associated
ABSCESSES
TREATMENT
SOURCE CONTROL
DRAIN via Percutaneous Catherer or Surgery
unable to FULLY DRAIN? –> duration could be WEEKS
based on the IMAGING
Treatment is the same as CIAI
CEFTRIAXONE or Cefotaxime
Polymicrobial
- *Enterics + Anaerobes**
- *Pseudomonas - if HIGH-severity or Healthcare-associated**
Presentation / Diagnosis + RISK FACTORS
- *CIAI**
- *Complicated Itraabdominal Infection**
CIAI = Secondary Peritonitis
Paracentesis = Protein >1g/dL
Ab Symptoms / Infection Symptoms / Imaging
Risk Factors for CIAI
CRITICALLY ILL in ICU / Trauma Patients / Surgical Procedures
ORGANISMS
- *CIAI**
- *Complicated ItraAbdominal Infection = Secondary Peritonitis**
Often POLYmicrobial:
- *ENTERICS**
- *E. Coli + Kleb**
- *GI ANAEROBES**
- *Bacteroides / Clostridium / Peptostreptococcus**
- PSEUDOMONAS*
- *Mainly if HIGH-SEVERITY** or HEALTHCARE-ASSOCIATED
TREATMENT
Community-Acquired MILD-MODERATE
CIAI
Complicated ItraAbdominal Infection = Secondary Peritonitis
- *CEFOXITIN**
- *Enteric + Anaerobic** Activity
- Ertapenem* –> only for pt w/ ho ESBL
or
METRONIDAZOLE** + **CEFTRIAXONE** or **Cefotaxime
TREATMENT
HEALTHCARE-ASSOCIATED
CIAI
Complicated ItraAbdominal Infection = Secondary Peritonitis
Invasive Device
H/O MRSA infxn/colonization
H/O Surgery/hospitilization / dialysis / long term care
Onset/culture > 48 hours after admission
Treatment is the SAME with High Risk / Severe CIAI
PIPERACILLIN / TAZOBACTAM
want to cover ALL
Enterics + Anaerobes + PSEUDOMONAS
Carbapenems –> reserved for ESBL
TREATMENT
HIGH-RISK / SEVERE Community-Aquired
CIAI
Complicated ItraAbdominal Infection = Secondary Peritonitis
ICU PATIENT
Advanced Age / Comorbidities
Immunocomprimised / Malignancy
DELAY in initial intervention >24 hours
Treatment is the SAME with Healthcare-Associated CIAI
PIPERACILLIN / TAZOBACTAM
want to cover ALL
Enterics + Anaerobes + PSEUDOMONAS
Carbapenems –> reserved for ESBL
TREATMENT
Community Acquired, Mild/Moderate
CHOLECYSTITIS
Infection/Inflammation of gallbladder
- does NOT need anaerobic activity*
- *Typically Sterile**
- *Enterics_ + _Enterococcus**
CEFTRIAXONE
TREATMENT
Healthcare-Associated or High Severity Community-Acquired
CHOLECYSTITIS
Infection/Inflammation of gallbladder
Enterics** + **Enterococcus
With additional coverage for:
ANAEROBES** + **PSEUDOMONAS
So treat with:
PIP/TAZO
or
CARBAPENEMS
except ERTAPENEM
ALSO:
SOURCE CONTROL –> REMOVE GALL BLADDER or ERCP
TREATMENT
CHOLANGITIS + Biliary-Enteric Anastamosis
Infection/Inflammation of bile ducts
Enterics** + **Enterococcus
With additional coverage for:
ANAEROBES** + **PSEUDOMONAS
So treat with:
PIP/TAZO
or
CARBAPENEMS
except ERTAPENEM
ALSO:
SOURCE CONTROL –> REMOVE GALL BLADDER or ERCP
Presentation / Diagnosis
Appendicitus
Accute Inflammation of Appendix related to obstruction
Presents with:
Deep Periumbical pain + Subsequent Right-lower quadrent pain
after 6-24 hours
Need to:
Rule out uterine/ectopic pregnancy
for child-bearing aged women
Treatment / Bacteria
APPENDICITIS
Polymicrobial
Enterics + Anaerobes + Streptococci
ABx Choice is SAME as Community-Acquired CIAI
CEFOXITIN
Enterics + Anaerobic
OR
Ceftriaxone** + **Metronidazole
When would we ADD:
EMPIRIC DAPTOMYCIN / LINEZOLID
to current:
CIAI Regimen?
+ Daptomycin or Linezolid +
Liver Transplant** w/ CIAI from **HepatoBiliary Tree
OR
known to be colonized with VRE
vancomycin resistant enterococcus
When would we ADD:
EMPIRIC VANCOMYCIN
to current:
CIAI Regimen?
+ Vancomycin +
Healthcare-Associated CIAI** + **Colonized w/ MRSA
OR
Previously FAILED treatment** + **Significant ABX Exposure
Treatment DURATION
for
Short-Corse Antimicrobial Therapy
Intrabdominal Infections
after SOURCE CONTROL:
(fix leak / aspirating abscess)
4 DAYS
