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Infectious Disease > Intra-abdominal Infections > Flashcards

Intra-abdominal Infections Flashcards

1
Q

By definition an IAI is:

A

A diverse set of diseases

Peritoneal inflammation in response to microorganisms with associated purulence in the peritoneal cavity

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2
Q

IAI classifications

A

Primary organ infected

Uncomplicated vs. complicated
Uncomplicated-infection contained in single organ (e.g., stomach) without anatomical disruption

Setting of acquisition
(CA-IAI) Community-acquired intra-abdominal infection

(HA-IAI) Healthcare- or hospital acquired-intra-abdominal infection

Severity of illness and risk

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3
Q

What makes an IAI complicated?

A

Extends beyond source organ into the peritoneal space

Peritoneal inflammation with:
Localized peritonitis –> abscess
Diffuse peritonitis

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4
Q

Intra-abdominal abscess

A

Purulent collection of fluid

Contains:

  • Necrotic debris
  • Bacteria
  • Inflammatory cells
  • Fibrous capsule

Walled off by inflammatory cells and adjacent organs

Hard for antibiotics to penetrate

Ideal environment for anaerobes

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5
Q

Tertiary peritonitis

A

Persistent or recurrent at least 48 hours after appropriate management of primary or secondary peritonitis

Associated with low virulence organisms in critically ill or immunosuppressed

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6
Q

Secondary peritonitis

A

Spread from another organ resulting in focal disease in the abdomen

Polymicrobial

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7
Q

Primary peritonitis

A

Infection of peritoneal cavity without an evident source in the abdomen

Spontaneous bacterial peritonitis

Monomicrobial

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8
Q

Primary peritonitis

A

Occurs in children and adults

10-30% of alcoholic cirrhotic patients (SBP)

Peritoneal dialysis patients average 1 episode

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9
Q

Secondary peritonitis

A

Account for 80-90% of intra-abdominal infections

Appendicitis is most common

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10
Q

Primary peritonitis

A

Bacteria enter via:

Bloodstream or the lymphatic system via gut transmigration

Indwelling peritoneal dialysis catheter

Fallopian tubes in females

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11
Q

Secondary peritonitis

A

Bacteria enter via:

Perforation of GI or female genital tracts after
Disease process
Trauma

Introduction during surgery
Contamination
Anastomotic leak

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12
Q

Which of the following DOES NOT represent a common etiology of primary peritonitis?

A.) Cirrhosis with ascites
B.) Trauma
C.) Peritoneal dialysis
D.) Nephrotic syndrome
E.) Spontaneous bacterial peritonitis
A

B.) Trauma

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13
Q

Microbiology of primary peritonitis

A

Normally monomicrobial

Cirrhotic ascites
E. coli (most common)
Other: Klebsiella spp., S. pneumoniae, and enterococci

Peritoneal dialysis
    Staphylococci
    Streptococci
    E. coli
    Klebsiella spp.
    Pseudomonas spp.
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14
Q

Microbiology of cIAI

Most common pathogens (Greater than 10%)

Facultative and aerobic gram-negative:

Gram-positive aerobic cocci:

Anaerobic:

A

Facultative and aerobic gram-negative:
Escherichia coli
Klebsiella species
Pseudomonas aeruginosa

Gram-positive aerobic cocci:
Streptococcus species
Enterococcus faecalis

Anaerobic:
Bacteroides fragilis 
Other Bacteroides species 
Clostridium species 
Prevotella species 
Peptostreptococcus species 
Eubacterium species
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15
Q

Which of the following DOES NOT represent a common pathogen (>10%) isolated from complicated IAIs?

A.) Escherichia coli 
B.) Streptococcus species 
C.) Bacteroides fragilis 
D.) Staphylococcus aureus
E.) Klebsiella species
A

D.) Staphylococcus aureus

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16
Q

Clinical presentation of primary and secondary peritonitis

A

Voluntary to involuntary abdominal guarding, abdominal tenderness and distension, faint bowel sounds.

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17
Q

Clinical presentation of primary peritonitis laboratory tests

A

Mildly elevated WBC, elevated fluid WBC (e.g., >250 leukocytes/mm3 in ascitic fluid)

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18
Q

Clinical presentation of secondary peritonitis laboratory tests

A

Leukocytosis, elevated hematocrit and BUN d/t dehydration, progresses to acidosis from vomiting

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19
Q

Diagnosing peritonitis

A

Ultrasound and CT
CT more difinitive

Fluid workup in primary peritonitis
>250 PMN/mm3 (ascitic) in SBP
>100/µL white cell count (dialysis effluent) in peritoneal dialysis catheter infection

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20
Q

Treatment of primary peritonitis

A

Cirrhotic ascites-SBP
Primary treatment:
Cefotaxime or ceftriaxone (preferred)
Duration of therapy: 5 days

Secondary prophylaxis
Ciprofloxacin, trimethoprim-sulfamethoxazole

Peritoneal dialysis
Primary treatment:
vancomycin + 3rd generation cephalosporin or aminoglycoside

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21
Q

Overall approach to IAI

A

NON-PHARM
SOURCE CONTROL

Evaluate microbial agents

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22
Q

Source control for IAI

A

“Considered fundamental to the treatment of most patients with IAI”

Undertake within 24 hours of diagnosis

Use least invasive procedure
Percutaneous drainage

23
Q

Antimicrobial approach

A

Patient risk category

Setting of acquisition

Previous resistance documented

Local resistance patterns

In general should cover:
Typical Gram-negative enterics
Gram-positive cocci
Obligate anaerobes

24
Q

Healthcare- or Hospital-Acquired-IAI definition

A

Infection developing greater than 48 hours after initial source control

Hospitalized for greater than 48 hours during current admission or within the previous 90 days

Residence in a skilled nursing or other long-term care facility within the previous 30 days

Home infusion therapy, home wound care, or dialysis within the preceding 30 days

Use of broad-spectrum antimicrobial therapy for 5 d or more during the preceding 90 days

25
Q

Which of the following patients would be classified as HA-IAI?

A.) 73 y/o who developed IAI 36 hours after initial source control
B.) 55 y/o who was hospitalized 30 days ago for surgical procedure
C.) 66 y/o who received home wound care 90 days ago
D.) 45 y/o that received 2d of vancomycin and piperacillin/tazobactam during a previous admission 75 days ago.
E.) 22 y/o with no PMH presenting with perforated appendicitis

A

B.) 55 y/o who was hospitalized 30 days ago for surgical procedure

26
Q

**Do NOT use first line**

A

Ampicillin/sulbactam (Unasyn)

Cefazolin + metronidazole

Cefoxitin/cefotetan

Tigecycline

Clindamycin (unless under 1 MONTH of age)

27
Q

Community-Acquired IAI

Treatment for LOW-RISK Patients

A

cefotaxime OR ceftriaxone + metronidazole

ertapenem

moxifloxacin OR ciprofloxacin + metronidazole
(if severe β-lactam allergy or local susceptibility demonstrated per antibiogram)

28
Q

Community-Acquired IAI

Treatment for HIGH-RISK Patients

A

piperacillin/tazobactam

cefepime OR ceftazidime + metronidazole

doripenem OR imipenem/cilastatin OR meropenem

aztreonam + vancomycin + metronidazole
(if severe β-lactam allergy)

29
Q

Which of the following would represent the most appropriate treatment for a lower-risk community-acquired IAI?

A.) Ciprofloxacin
B.) Ciprofloxacin + metronidazole
C.) Ceftriaxone + metronidazole
D.) Ertapenem
E.) Cefepime + metronidazole
A

C.) Ceftriaxone + metronidazole

30
Q

HA-IAI: microbiology

A

Decreased incidence of:
E. coli
Aerobic streptococci

***Increased incidence of:
Enterobacter spp.
Pseudomonas aeruginosa and Acinetobacter spp.
Enterococcus spp.
S. aureus
Candida spp.
Multi-drug resistant organisms (MDROs)
31
Q

HA-IAI: microbiology Treatment:

A

piperacillin/tazobactam

Or

cefepime + metronidazole

OR

imipenem/cilastatin

OR

ceftazidime + metronidazole

32
Q

HA-IAI: microbiology Treatment for E. faecalis

A 
piperacillin/tazobactam 
OR
imipenem/cilastatin
w/wo
Addition of ampicillin or vancomycin
33
Q

HA-IAI: microbiology Treatment for E. faecium

A

vancomycin

34
Q

HA-IAI: microbiology Treatment for Vancomycin resistant Enterococcus spp.

A

daptomycin

linezolid

35
Q

Which of the following regimens would NOT provide adequate anti-Enterococcal coverage?

A.) Piperacillin/tazobactam
B.) Cefepime + metronidazole
C.) Imipenem/cilastatin
D.) Vancomycin + cefepime + metronidazole
E.) Vancomycin + ceftazidime/avibactam
A

B.) Cefepime + metronidazole

36
Q

Treatment of HA-IAI: anti-staphylococcal therapy:

Considered at risk for MRSA in HA-IAI:
Known colonization
Patient has several risk factors
Advanced age
Co-morbid medical conditions
Previous hospitalization or surgery
Significant recent exposure to antibiotics

A

Treatment options

Vancomycin
Daptomycin
Linezolid

37
Q

Treatment options for MDR GNRs

ESBL-producing or AmpC-B-lactamase producing Enterobacteriaceae

A

Use of a broad-spectrum carbapenem

38
Q

Treatment options for MDR GNRs

Klebsiella pneumoniae carbapenemas (KPC)-producing Enterobacteriaceae

A

Combination therapy with a broad-spectrum carbapenem plus and aminoglycoside, polymyxin, or tigecycline

OR

ceftazidime/avibactam

39
Q

Treatment options for MDR GNRs

MDR strains of Pseudomonas aeruginosa

A

Combination therapy with an aminoglycoside plus colistin

OR

ceftolozane/tazobactam

OR

ceftazidime/avibactam

40
Q

Treatment options for MDR GNRs

MDR strains of Acinetobacter baumannii

A

Combination therapy with a broad-spectrum carbapenem plus(+) an aminoglycoside, polymyxin, or tigecycline

41
Q

When in an IAI do you add antifungal therapy?

A

Patients at risk
Upper gastrointestinal perforations
Recurrent bowel perforations
Surgically treated pancreatitis
Received prolonged courses of broad-spectrum antimicrobial therapy
Known to be heavily colonized with Candida

42
Q

Antifungal therapy for IAI Candida albicans

A

Echinocandin for critically ill patients
and
Fluconazole for less critically ill patients

43
Q

Antifungal therapy for IAI Non-Candida albicans

A

Echinocandin

44
Q

Which of the following regimens would be considered the most appropriate treatment of non-Candida spp. isolates in a critically ill patient?

A.) Micafungin
B.) Liposomal-amphotericin B
C.) Fluconazole
D.) Voriconazole
E.) Isavuconazole
A

A.) Micafungin

45
Q

Echinocandin drugs

A

Cancidas - Generic name: caspofungin

Eraxis - Generic name: anidulafungin

Mycamine - Generic name: micafungin

46
Q

Timing and dosing of IAI treatment

A

Initiation within one hour or as soon as possible after the time of diagnosis is made in septic or septic shock patients

Re-administer an antimicrobial agent within one hour before start of source control procedure

47
Q

What is treatment failure?

A

Progressive organ dysfunction within 24-48 hours after source control

No clinical improvement in organ dysfunction 48+ hours after source control

Persistent signs of inflammation 5-7 days after source control

48
Q

Management of treatment failure?

A

Repeat imaging
Pursue additional source control
Obtain peritoneal cultures
Adjust antimicrobials

49
Q

Duration of antimicrobial therapyof IAI

A

Generally 24 hours

Adequate source control - 4 days

Inadequate source control - 5-7 days

50
Q

A 45 y/o with a complicated intra-abdominal infection and associated intra-abdominal abscess resulting from gun shot wound received adequate source control today following surgical intervention. Based on culture results the patient is on adequate antimicrobial therapy. How many more days of therapy does the patient require?

A.) 4 days
B.) 6 days
C.) 7 days
D.) Stop therapy today
E.) 14 days
A

A.) 4 days

51
Q

Oral completion of therapy?

A

Amoxicillin/clavulanate
Moxifloxacin
Ciprofloxacin + metronidazole

Key points
Good bioavailability
Return of gastrointestinal function 
Complete short course
DO NOT PROLONG THERAPY!
52
Q

Biliary Infections: Cholecystis

A

RUQ pain, Murphy’s sign, tachycardia, fever, leukocytosis

53
Q

Biliary Infections: Charcot’s triad:

A

jaundice, RUQ pain, fever, Reynold’s pentad (Charcot’s plus); hypotension, confusion; leukocytosis; elevated bilirubin; elevated GTT

Infectious Disease (56 decks)

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