Exam 4 lecture 1 Flashcards
What are the definitions of intraperitoneal and retroperitoneal organs? What are the organs?
Intraperitoneal- Completely covered with Visceral peritoneum
- Stomach
- 1st part Duodenum
-Jejunum
-Ileum
-Transverse colon
-Sigmoid colon
-Liver
-spleen
Retroperitoneal- partially covered with peritoneum
-Kidneys
-Ureters
-Suprarenal glands
-Rectum
Name the types of intra abdominal infections
- Diverticulitis (+/- perforation/abscess)
- Appendicitis (+/- rupture)
- Cholecystitis
- Intra abdominal abscess
- Peritoneal dialysis related peritonitis
- Spontaneous bacterial peritonitis
- Necrotizing pancreatitis
- Cholangitis
- Cholecystitis
What is primary peritionitis? Diseases?
- peritoneal dialysis related peritonitis
- Spontaneous bacterial peritonitis
What are the secondary peritonitis
diverticulitis
appendicitis
Cholecystitis
Cholangitis
Necrotizing pancreatitis
Intra abdominal abscess
Define uncomplicated and complicated infection
Uncomplicated infection
- Confined within visceral structure (gall bladder, liver, spleen, kidneys)
- does not extend into peritoneum
Complicated infection
-extends beyond a single organ into peritoneal space and associated with peritonitis
WHo is at highest risk for SBP (spontaneous bacterial contamination)? Most common monomicrobial? Source of contamination?
No obvious source for contamination
patient at highest risk- Hepatic failure and ascites- alcoholic cirrhosis
E coli is most common monomicrobial
Clinical presentation of SBP
-Abdominal pain
-N/V/D
-Fevers, chills\reduced/absent bowel sounds
-altered mental status/encephalopathy (especially in pts with alcoholic cirrhosis)
What is needed for diagnosis of SBP
S/s of infection
Ascitic fluid analysis
What lab results do we look at for ascitic fluid analysis of SBP (What number suggests)
TNC x Bands/neutrophils bdy fluid= ANC
absolute neutrophil count > 250 is SBP
What are the recommended empiric treatment options of SBP
Ceftriaxone**
Cefepime
Piperacillin/tazobactam
Meropenem
What to consider in tx of SBP if risk for MRSA present
Consider addition of Vancomycin, linezolid, daptomycin
What to use for anaerobic coverage for SBP
B lactam/ B lactamase inhibitor
Carbapenem
Metronidazole (ceftriaxone, cefepime)
SBP tx duration
5-7 days
14-21 days for peritonitis patients undergoing CAPD
What to use for secondary prophylaxis for SBP
TMP/SMX, PO QD or ciprofoxacin 500 mg PO QD
most common microorganisms for secondary intra abdominal infections
POLYMICROBIAL
aerobic (-)- E coli
Aerobic (+)- strep viridians
Anaerobic bacteria- bacteroides
Fungi- candida
What makes secondary intra abdominal infections so unique
Multiple organ systems affected
- GI tract- bowel paralysis
- CV- fluid shifts
- Respiratory- hypoxemia
- Renal- decreased renal perfusion
bacterial synergy
- enterobacterales creates perfect envt for anaerobes
-anaerobes cause abscess and have several virulent factors
s/s of secondary intrabadominal infections
-abdominal pain and distention
- N/V
-Fevers +/- chills
- loss of appetite
- Inability to pass flatus and/or feces
physical exam/ vital signs of secondary intra abdominal infections
Tachypnea, tachycardia
Hypotension
SIgnificant abdominal tenderness
Rigidity of abdominal wall
Reduced or absent bowel sound
What are the two pillars of intra abdominal infection tx
Source control
Antimicrobial therapy
What are examples of source control procedures? Why are they important?
- Repair perforations
- resection of ifected organs/tissue
- Removal of foreign material
- Drain purulent collections
Important to obtain cultures
What are the 3 main considerations for empiric antibiotic selection for secondary intra abdominal infection
- select agent or combination of agents with high likelihood to cover common organisms. (must look at local antibiogram)
- Consider if enterococci coverage is necessary
- consider if antifungal coverage is required
When are agents not recommended for intra abdominal infections?
agents not recommended if resistance rates exceed 10-20% for e coli
When is enterococci coverage not necessary for IAI?
(not necessary for mild- moderate severity of community acquired IAI.
When is enterococci coverage necessary for IAI
high severity IAI
hx of recent cephalosporin use
immunocompromised
biliary source of infection
hx of valvular heart disease
prosthetic intravascular material
when can we consider antifungal coverage
only add if isolated in culture
May consider if patient not improving on appropriate antibiotic therapy
empiric antibiotic regimen for community acquired mild-moderate secondary IAI
enterococci not covered
- ceftriaxone
-cefazolin
- ciprofloxacin
- levofloxacin
cefoxitin
- Ertapenem
- Tigecycline
Empiric therapy for community qcquired high severity and healthare associated IAI
Piperacillin/tazobactam
Meropenem
Cefepime
Ciprofloxacin
Levofloxacin
secondary IAI candida albicans (fungi) tx? Non albican tx
Flucanozole
use micafungin if treating candida species other than albicans on culture
Is ampicillin/sulbactam included in tx of IAI
no, e coli resistance is high for ampicillin/sulbactam
What is a note about IAI about anaerobic bacteria
Common to maintain anaerobic coverage even if culture does not isolate anaerobic bacteria
common oral antibiotic regimens for IAI for de escalation
Amox/clav (can be dosed TID)
Cefpodoxime
if possible confirm susceptbility
Cephalexin
Cefadroxil
Ciprofloxacin
Levofloxacin
TMP/SMX
Tx duration for general tx, diverticulitis, appendicitis, cholecystitis, bowel injuries repaired within 12 hrs
general tx duration- 4-7 days after source control
Diverticulitis- uncomplicated- no antibiotic, moderate/severe- 5-10 days
appendicitis, cholecystitis and bowel injuries- 24 hrs
which organisms do not need to be covered empirically for appendicitis, e coli, enterococcus, bacteroides, s. aureus
S aureus
do ceftriaxone or metronidazole cover enterococcus?
no
What type of microbe is c diff
Gram positive
spore forming
Obligate anaerobic
two toxins procuded by c diff? What is the more virulent strain?
TcdA (inflammatory enterotoxinc) and TcdB (cytotoxin)
BI/NAP1/027 (high severity and toxicity)
How is C diff transmitted from person to person
Fecal-oral route through spores
C diff risk factors
Antibiotic exposure
Healthcare exposure
age > 65
proximity to person with C diff
Chemo
GI surgery
Immunosuppression
use of antacids
what are the antibiotics with highest risk for C diff
fluoroquinolones
clindamycin
3rd/4th gen cephalosporins (specifically ceftriaxone)
carbapenems
pathogenesis of c diff
disruption of colonic microflora
source and introduction of C diff to colon
Multiplication of c diff
colon becomes edematous
two primary symptoms of c diff
profuse, watery or mucoid green, foul smelling diarrhea
abdominal pain
When to test for C diff? 3 testing methods for C diff?
When to test- 3 or more profuse, watery or mucoid green, foul smelling stools in 24 hrs
3 tests
1. nucleic acid amplification test (NAAT) alone
2. antigen test (GDH) + toxin A/B test
3. NAAT + toxin A/B test
is repeat testing for C diff recommended
no
s/s of different C diff classifications
Non severe- WBC< 15,000
Scr < 1.5
severe- WBC > 15,000
Scr > 1.5
Fulminant- hypotension or shock, toxic megacolon
What are the different C diff treatment options
Oral vancomycin (standard of care)
Fidaxomixin (narrower spectrum)
metronidazole- no longer 1st line
PK/PD of oral vanc
extremely poor oral absorption
C diff only indication for oral vanc
doses of oral vanc
standard- vanc 125 mg PO Q6h
fulminant- vanc 500 mg PO Q 6H
biggest barrier to fidaxomicin
4500 dollar cost of use
c diff infection treatment for initial episode non severe and initial episode severe
initial episode non severe- Fidaxomicin, vancomicin, metronidazole (only if other options unavailable/unfeasible)
Initial episode severe- fidaxomicin
vancomycin
would u recommend loperamide for c diff
no
general approach with recurrent c diff
change something, either drug or dosing regimen
What treatment options to use for first CDI recurrence (in order of preference)? Second or subsequent CDI recurrence
-Fidoxomicin 200 mg PO BID x 10 days
-Vancomycin 125 mg PO Q6H x 10 days
- Fidaxomicin 200 mg PO BID x 5 days, then 200 mg PO every other day x 20 days
- Vanc tapered and pulsed
Second recurrence- same drugs, just select different treatment
How to treat fulminant CDI? WHat if ileus present?
Vancomycin 500 mg PO Q6H
+ Metronidazole 500 mg IV Q 8H
IF ILEUS PRESENT, consider adding vanc 500 mg rectally q6h
What are the 3 biggest risk factors for CDI recurrence
Age> or = 65
Immunocompromised host
Severe CDI on presentation
What is FMT? Potential indications?
- administration of fecal material from a healthy person to restore a balanced gut microbiome
- Utilized as both a treatment option and method to reduce reccurence
Indication
- 3 or more episodes of CDI
- Poor response to initial antibiotic therapy for CDI
What is rebyota? Compare to other FMTs
Fecal microbiota suspension
administered via rectal tube 24-72 hrs after tx completion
compare vowst to rebyota
Vowst us bacterual spore suspension (oral)
4 capsules PO x 3 days starting 2-4 days after tx completion
Compare bezlotoxumab to other drugs used after FMT
Benzlotoxumab is a monoclonal antibody targeting C diff toxin B to neutralize itseffect
IV x 1 dose during CDI tx
what to be careful of when giving bezlotoxumab
Caution in pts with CHF (increased risk for mortality and CHF)
who should not receive probiotics
Bowel perforation patients
patients in ICU
Do patient applications at 1 hour 24 mins on march 10 lecture
