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835 > Intra-abdominal Infections > Flashcards

Intra-abdominal Infections Flashcards

1
Q

Intra-Ab Infections

A
  • Within peritoneal or retroperitoneal cavity
  • Peritoneal cavity contains: Stomach, jejunum, ileum, colon, appendix, liver, gallbladder, spleen
  • Retroperitoneal space contains: duodenum, pancreas, kidneys
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2
Q

Primary Peritonitis

A
  • Infection of peritoneal cavity without evident source in the abdomen
  • Develops mostly in peritoneal dialysis
  • Can also be seen in those with liver disease (alcoholic cirrhosis)
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3
Q

Primary Peritonitis Microbiology

A
  • Often a single organism that is introduced by a catheter or translocation from bloodstream or lymphatic system
  • Different organisms connected to different comorbidities
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4
Q

Microbiology + Cirrhotic Ascites

A
  • Gram negative more common: E. coli, Klebsiella pneumoniae

- Gram positive: S. pneumoniae, Viridans streptococcus

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5
Q

Microbiology + PD

A
  • Peritoneal dialysis
  • Gram positive more common: Coag “neg” staphylococci, S. aureus, streptococci
  • Gram negative: increased mortality, pseudomonas and E. coli more common
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6
Q

Peritonitis Presentation/Diagnosis

A
  • Symptoms: N/V, fever, abdominal tenderness/distension, hypotension, cloudy dialysate fluid (PD)
  • Lab tests: elevated WBCs, ascitic fluid contents/amounts
  • Culture from ascitic fluid (negative in large percent of patients)
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7
Q

Ascitic Fluid + Abnormal Labs

A
  • In cirrhosis: >250 PMNs/mm3

- In PD: WBCs > 100 cells/mm3, >50% PMNs

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8
Q

Primary Peritonitis Treatment + Cirrhosis

A
  • Cefotaxime 2g IV q8h
  • Ceftriaxone 2g IV q24h
  • Duration: 5-10 days
  • Prophylactic therapy for those who have 1 or more episodes of SBP
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9
Q

Primary Peritonitis Prophylaxis + Cirrhosis

A
  • Bactrim DS daily for 5 days/week

- Cipro 750 mg weekly or 500 mg daily

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10
Q

Primary Peritonitis Treatment + PD

A
  • Vanco + Cefepime
  • Vanco + Ceftazidime
  • Duration: 14-21 days
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11
Q

Secondary Peritonitis

A
  • Originate in the abdomen
  • Many possible causers
  • Typically polymicrobial
  • Surgery is usually necessary
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12
Q

Causers of Secondary Peritonitis

A
  • Ulceration, ischemia, or obstruction
  • Operation contamination
  • Blunt/penetrating trauma
  • Diverticulitis
  • Appendicitis
  • Cholecystitis
  • Female genital tract (postoperative uterine infection or endometritis)
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13
Q

Appendicitis

A
  • Normally occurs in 2nd or 3rd decade or life
  • Early presentation: dull, non-localized RLQ pain, bowel irregularity, flatulence
  • Late presentation: pain/tenderness, more localized, N/V
  • Perforation likely if T>103F, leukocytes >15,000 cells/mm3
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14
Q

Common Community Pathogens

A

Gram Negative

  • E. Coli
  • Klebsiella spp.
  • Proteus spp,

Gram Positive

  • Streptococcus spp.
  • Enterococcus spp.
  • S.aureus

Anaerobes

  • Bacteroides spp.
  • Peptostreptococcus spp.
  • Clostridium spp.
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15
Q

Appendicitis Symptoms

A
  • N/V
  • Fever
  • Tenderness/distension in abdomen
  • Hypotension
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16
Q

Appendicitis Complications

A
  • Abscess(es)
  • Gangrene bowel
  • Intraperitoneal adhesions
  • Septic Shock
17
Q

Secondary Peritonitis Diagnosis

A
  • Laboratory tests: elevated WBCs
  • Culture fluid collected during surgery or from drain
  • **Blood cultures usually don’t provide relevant data
  • CT imaging
18
Q

Secondary Peritonitis Treatment Goals

A
  • Correction of disease processes or injuries
  • Surgical intervention for “source control” or abscess drainage
  • Fluid resuscitation within 6 hr
  • Empiric antibiotics should be administered in ED once suspected
19
Q

Mild-Moderate Secondary Peritonitis

A
  • APACHE II score <15
  • Perforated or abscessed appendicitis
  • Acute diverticulitis
20
Q

Severe Secondary Peritonitis

A
  • APACHE II score >= 15
  • Advanced age
  • Immunocompromised
  • Nosocomial infections
21
Q

Secondary Peritonitis Treatment + CA + Mild-Mod

A
  • Empiric should cover Gram “-“ bacilli, Gram “+” streptcoccus, and anaerobes
  • Single agents: cefoxitin, ertapenem, moxifloxacin
  • Combo: cefazolin, cefuroxime, ceftriaxone, ciprofloxacin, or levofloxacin PLUS metronidazole
22
Q

Secondary Peritonitis + CA + Mild-Mod + Tigecycline

A
  • ONLY IV
  • Activity against required empiric bacterial types
  • ADE: Nausea
  • No renal or hepatic adjustments necessary except CP C
  • FDA Warning: Increased risk of death
23
Q

Secondary Peritonitis + CA + Mild-Mod + Not Recommended Treatments

A
  • Empiric Unasyn
  • Cefotetan or clindamycin
  • AMG
  • *All experience resistance or toxicity**
  • Empiric coverage of pseudomonas, enterococcus, MRSA, or Candida
24
Q

Secondary Peritonitis Treatment + Severe

A
  • Empiric should cover Gram “-“ bacilli, Gram “+” streptcoccus, anaerobes, AND pseudomonas
  • Single agents: Primaxin, meropenem, doripenem, OR zosyn
  • Combo: Cefepime, ceftazadime, ciprofloxacin, or levofloxacin PLUS metronidazole
25
Q

Secondary Peritonitis Treatment + Severe/Nosocomial Infection + MRSA

A

Empiric MRSA coverage:

  • Colonized with MRSA
  • Invasive device at admission
  • Surgical history
  • Dialysis
  • Residence in long-term care facility in last 12 months

Treatment: Vanco

26
Q

Secondary Peritonitis Treatment + Severe/Nosocomial Infection + Enterococcus

A

Need coverage for:

  • Postoperative infections
  • Hx of cephalosporins/abx use that may select for enterococcus
  • Immunocompromised
  • Positive cultures

Treatment options:

  • Ampicillin
  • Zosyn
  • Vanco
27
Q

Secondary Peritonitis Treatment + Severe/Nosocomial Infection + Fungal

A
  • NOT generally covered
  • Conditions necessary to meet before treating
  • Treatment options: Fluconazole or enchinocandinscan be used in critically ill patients or in resistant organisms
28
Q

Conditions to Treat Fungal Organisms

A

Cover if culture positive for Candida AND

  • Patient received immunosuppressed therapy recently
  • Perforation of gastric ulcer on acid suppression
  • Perforation due to malignancy
  • Recurrent intra-abdominal infection
29
Q

New Alternative Agents

A
  • Ceftolozane-Tazobactam: for high risk gram “-“ bacteria resistance, use with metro
  • Ceftazidime-avibactam: for high risk gram “-“ bacteria resistance, use with metro
  • Eravacycline: similar activity to tigecycline with lower MICs
30
Q

General Duration of Therapy

A
  • Typically 4-7 days unless difficult to control
  • May complete Tx with equivalent PO Tx (consider local susceptibilities)
  • Surgical prophylaxis is sufficient for localized processes
31
Q

Equivalent PO Tx

A
  • Oral cephalosporin (Cephalexin/cefixime + Metro)
  • Augmentin
  • Moxifloxacin
  • Cipro/levo + Metro
32
Q

Localized Processes for Surgical Prophylaxis

A
  • Nonperforated appendicitis
  • Cholecystitis
  • Bowel obstruction/infarction
  • Traumatic injury operated on within 12 hours

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