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PHRM 835 > Intra-Abdominal Infections > Flashcards

Intra-Abdominal Infections Flashcards

1
Q

Intra-abdominal infection

A

infection within the peritoneal cavity (or retroperitoneal cavity)

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2
Q

Peritoneal cavity contains

A
  • Stomach, jejunum, ileum, colon
  • Appendix
  • Liver
  • Gallbladder
  • Spleen
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3
Q

Retroperitoneal space contains

A
  • Duodenum
  • Pancreas
  • Kidneys
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4
Q

Primary Peritonitis

A

infection of the peritoneal cavity without an evident source in the abdomen

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5
Q

Primary peritonitis develops in

A
  • Peritoneal dialysis

- Patients with alcoholic cirrhosis (liver disease)

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6
Q

Primary peritonitis may develop as a result of?

A

Ascites or abnormal accumulation of abdominal fluids

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7
Q

Signs and symptoms of primary peritonitis

A
  • N&V
  • Fever
  • Abdominal tenderness
  • Abdominal distension
  • Hypotension
  • Cloudy dialysate fluid
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8
Q

Secondary Peritonitis

A

disease process that originates within the abdomen

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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)
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10
Q

What is secondary peritonitis usually caused by?

A

polymicrobial infections

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11
Q

Is surgery necessary in primary or secondary peritonitis?

A

secondary peritonitis

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12
Q

What is the most common cause of secondary peritonitis?

A

appendicitis

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13
Q

Appendicitis usually occurs in which part of life?

A

second or third decade of life

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14
Q

Appendicitis presentation occurs as

A
  • Early symptoms
  • Later symptoms
  • Perforation
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15
Q

Appendicitis early symptoms

A

Dull, Non-Localized Right Lower Quadrant (RLQ) pain, bowel irregularity, and flatulence

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16
Q

Appendicitis later symptoms

A

Pain / Tenderness, more localized pain, nausea and vomiting

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17
Q

Appendicitis perforation likely if patient presents with?

A
  • Temperature greater than 103 °F

- Leukocytes > 15,000 cells / mm3

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18
Q

Signs and symptoms of secondary peritonitis

A
  • Nausea & Vomiting
  • Fever
  • Abdominal Tenderness
  • Abdominal distension
  • Hypotension
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19
Q

Secondary peritonitis complications

A
  • Abscesses (or Abscesses)
  • Intraperitoneal Adhesions
  • Gangrene Bowel
  • Septic Shock
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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
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21
Q

Primary Peritonitis Cirrhotic Ascites can be caused by which organisms

A
  • Gram-negative

- Gram-positive

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22
Q

Primary Peritonitis Cirrhotic Ascites Gram-Negative Organisms?

A
  • Escherichia coli

- Klebsiella pneumoniae

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23
Q

Primary Peritonitis Cirrhotic Ascites Gram-Positive Organisms?

A
  • Streptococcus pneumoniae

- Viridians streptococcus

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24
Q

Primary Peritonitis Peritoneal Dialysis can be caused by which organisms

A
  • Gram-negative

- Gram-positive

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25
Q

Primary Peritonitis Peritoneal Dialysis Gram-Positive organisms?

A
  • Coagulase-Negative Staphylococci (CoNS)
  • Staphylococcus aureus
  • Streptococci
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26
Q

Primary Peritonitis Peritoneal Dialysis Gram-Negative organisms?

A
  • Escherichia coli

- Pseudomonas aeruginosa

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27
Q

For primary peritonitis in cirrhotic ascites, which organism is most common pathogen?

A

Gram-negative organisms

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28
Q

For primary peritonitis in peritoneal dialysis, which organism is most common pathogen?

A

Gram-positive organisms

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29
Q

For primary peritonitis in peritoneal dialysis, gram negative organisms are associated with increased?

A

mortality

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30
Q

Secondary Peritonitis Common Pathogens in Community-Acquired Infections

A
  • Gram-negative
  • Gram-positive
  • Anaerobes
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31
Q

Secondary Peritonitis Gram negative causative pathogens

A
  • E.coli
  • Klebsiella species
  • Proteus species
32
Q

Secondary Peritonitis Gram positive causative pathogens

A
  • Streptococcus species
  • Enterococcus species
  • Staphylococcus aureus
33
Q

Secondary Peritonitis anaerobe causative pathogens

A
  • Bacteroides species
  • Peptostreptococcus species
  • Clostridium species
34
Q

Which of the following agents is likely to have activity against B. fragilis?

A. Levofloxacin
B. Metronidazole
C. Ceftriaxone
D. Amoxicillin
E. Gentamicin
A

B. Metronidazole

35
Q

Primary Peritonitis Treatment in Cirrhosis

A
  • 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
Q

When is primary peritonitis prophylaxis therapy needed?

A

For patients who have had more than 1 episode of Spontaneous Bacterial
Peritonitis (SBP)

37
Q

primary peritonitis prophylaxis therapy

A
  • Bactrim® double-strength (DS) daily for 5 days per week

- Ciprofloxacin (Cipro®), 750 mg weekly (or 500 mg daily)

38
Q

Primary Peritonitis Treatment in Peritoneal Dialysis

A
  • Vancomycin + Cefepime for 14 – 21 days

- Vancomycin + Ceftazidime for 14 – 21 days

39
Q

Secondary Peritonitis Treatment Goals

A
  • 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
Q

Secondary Peritonitis Mild-to-Moderate Infection

A
  • APACHE II Score < 15
  • Perforated or Abscessed Appendicitis
  • Acute Diverticulitis
41
Q

Secondary Peritonitis Severe Infection

A
  • APACHE II Score of 15 or more
  • Advanced Age
  • Immunocompromised Patient
  • Nosocomial Infections (e.g., Post-Operative Infections)
42
Q

For Secondary Peritonitis Community-Acquired Mild-to-Moderate Infections,
Empiric Antibiotics should be active against:

A
  • Enteric Gram-Negative Bacilli
  • Enteric Gram-Positive Streptococci
  • Anaerobes
43
Q

Secondary Peritonitis Community-Acquired Mild-to-Moderate Infection Single Agent Regimen

A

Cefoxitin, Ertapenem or Moxifloxacin

44
Q

Secondary Peritonitis Community-Acquired Mild-to-Moderate Infection Combination Therapy

A
  • Cefazolin
  • Cefuroxime
  • Ceftriaxone
  • Ciprofloxacin
  • Levofloxacin in combination with Metronidazole
45
Q

Community-Acquired Mild-to-Moderate Infections NOT Recommended Agents

A
  • 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
Q

Which of the following agents has activity against P. aeruginosa?

a. Moxifloxacin
b. Ceftriaxone
c. Ertapenem
d. Cefepime
e. Ampicillin with Sulbactam

A

d. Cefepime

47
Q

Secondary Peritonits Community-Acquired Severe Infections Empiric Antibiotics should be active against?

A
  • Enteric Gram-Negative Bacilli
  • Enteric Gram-Positive Streptococcus
  • Anaerobes
  • Pseudomonas aeruginosa
48
Q

Secondary Peritonits Community-Acquired Severe Infections Single Agent Regimen

A

Imipenem with Cilastatin (Primaxin®), Meropenem,

Doripenem, OR Piperacillin with Tazobactam (Zosyn®)

49
Q

Secondary Peritonits Community-Acquired Severe Infections Combination Therapy

A
  • Cefepime
  • Ceftazidime
  • Ciprofloxacin
  • Levofloxacin in combination with Metronidazole
50
Q

Cefoxitin Dose

A

2 g IV q6h

51
Q

Ertapenem Dose

A

1 g IV q24h

52
Q

Moxifloxacin Dose

A

400 mg IV / PO q24h

53
Q

Cefazolin Dose

A

2 g IV q8h

54
Q

Ceftriaxone Dose

A

2 g IV q24h

55
Q

Ciprofloxacin Dose

A
  • 400 mg IV, q12h

- 400 mg IV, q8h

56
Q

Levofloxacin Dose

A

750 mg IV, q24h

57
Q

Cefepime Dose

A

2 g IV, q8h

58
Q

Imipenem w/ Cili Dose

A

1 g IV, q8h

59
Q

Meropenem Dose

A

1 g IV, q8h

60
Q

Metronidazole Dose

A

500 mg IV, q8h

61
Q

Severe / Nosocomial Infections Empiric MRSA coverage is required in the following cases

A
  • 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
Q

Severe / Nosocomial Infections Empiric MRSA coverage therapy

A

Vancomycin, 15 mg / kg IV, q8h – q24h

63
Q

Severe / Nosocomial Infections Enterococcus coverage is required in the following cases:

A
  • Post-Operative Infections
  • History of Cephalosporin antibiotic use that may select for Enterococcus
  • Immunocompromised patients
  • Positive cultures
64
Q

Severe / Nosocomial Infections Enterococcus coverage therapy

A
  • Ampicillin, 2 grams IV, q4h
  • Piperacillin with Tazobactam, 3.375 g IV q6h
  • Vancomycin, 15 mg / kg IV, q8h – q24h
65
Q

Empiric Fungal Coverage is NOT recommended!

Only use IF culture is positive for Candida AND patient has:

A
  • Recently received immunosuppressive therapy
  • Perforation of gastric ulcer on acid suppression
  • Perforation due to malignancy
  • Had recurrent Intra-Abdominal Infections
66
Q

Empiric Fungal Coverage for Candida therapy

A
  • Fluconazole, 400 mg IV, daily

- Echinocandins may be used in critically ill patients, or if organism is resistant

67
Q

Severe / Nosocomial Infections Duration of Therapy

A

Typically 4-7 days, unless difficult to achieve adequate source of infection control

68
Q

Adequate source control of the infection is shown by

A

Afebrile, normal White Blood Cell Count (WBC), return of bowel function

69
Q

Patient may complete treatment with equivalent PO treatment such as

A
  • Oral Cephalosporin (Cephalexin / Cefixime + Metronidazole)
  • Amoxicillin with Clavulanate (Augmentin®)
  • Moxifloxacin
  • Ciprofloxacin (or Levofloxacin) + Metronidazole
70
Q 
Surgical Prophylaxis (less than 24 hours) is sufficient for localized
processes, such as
A
  • Non-Perforated Appendicitis
  • Cholecystitis
  • Bowel Obstruction / Infarction
  • Traumatic Injury operated on within 12 hours
71
Q

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?

A

Disease process originating within the abdomen (Secondary Peritonitis);
Gram-Negative Enterococci and Anaerobes

72
Q

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)?

A

Cefoxitin, 2 g IV, q6h (for mild-to-moderate infection)

73
Q

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
A

B. 4–7days

74
Q

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?

A

Her regimen did NOT include Metronidazole with her cephalosporin for
Anaerobic coverage

75
Q

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?

A

Cefotaxime, 2g IV, q8h for 10 days

Ceftriaxone, 2 g IV, q24h for 10 days

76
Q

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?

A

Depending on her response, we would recommend no further therapy

PHRM 835 (5 decks)

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