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Infectious Diseases (4th year) > Intra abdominal infections - DONE > Flashcards

Intra abdominal infections - DONE Flashcards

1
Q

What is a part of the peritoneal cavity?

A
  • stomach
  • jejunum, ileum
  • appendix
  • large intestine (colon)
  • liver
  • gallblader
  • spleen
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2
Q

What is a part of the retroperitoneal space?

A
  • duodenum
  • pancreas
  • kidneys
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3
Q

What are the common intra-abdominal infections?

A
  • appendicitis
  • peritonitis
  • intra-abdominal abscess
  • diverticulitis
  • antibiotic-associated diarrhea (c.difficile)
  • food poisonings/traveler´s diarrhea
  • gastritis (h.pylori)
  • cholecystitis
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4
Q

IMAGE

A

SLIDE 5

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5
Q

What is the normal microflora of the stomach?

A
  • H.pylori
  • Streptococci
  • Lactobacilli
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6
Q

What is the normal microflora of the upper small intestine?

A
  • Aerobes:
    • enterococci
    • staphylococci
    • lactobacilli
    • e.coli
    • klebsiella (enterobacteriace)
  • Anaerobes:
    • bacteroides
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7
Q

What is the normal microflora of the ileum?

A
  • Aerobes:
    • streptococci
    • staphylococci
    • e.coli
    • klebsiella
    • enterobacter
  • Anaerobes:
    • bacteroides
    • clostridium
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8
Q

What is the normal microflora of the large intestine?

A
  • Aerobes:
    • e.coli
    • enterococci
    • staphylococci
  • Anaerobes:
    • bacteroides
    • peptostreptococci
    • clostridium
    • bifidobacteria
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9
Q

When does the bacterial translocation occur?

A

occurs when bacteria leave the gut through its mucosal lining

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10
Q

What causes bacterial translocation?

A
  • too much growth of bacteria in the small intestine
  • reduced immunity of the host
  • increased gut lining permeability
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11
Q

LPS =

A

Lipopolysaccharide

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12
Q

What is Lipopolysaccharide (LPS)?

A

Lipopolysaccharide (LPS) is a component of gram-negative bacteria’s cell wall

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13
Q

How does the LPS translocate?

A

LPS translocates through permeable tight junctions of the gut

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14
Q

What does the LPS do when it translocates?

A

Activates inflammation cascade through toll-like receptor 4 (TLR 4) in the liver

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15
Q

What is peritonitis?

A

Inflammation of the serous lining of the peritoneal cavity

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16
Q

What causes peritonitis?

A
  • Microorganisms
  • Chemicals
  • Irradiation
  • Foreign body injury
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17
Q

Primary peritonitis:

A
  • no focus if disease is evident

- bacteria transported from blood stream to peritoneal cavity (CAPD, cirrhosis)

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18
Q

Secondary peritonitis:

A
  • acute perforation of the GI tract (66%)
  • post-operative peritonitis (24%)
  • post-traumatic peritonitis (10%)
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19
Q

What is the most common cause of secondary peritonitis

A

acute perforation of the GI tract (66%)

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20
Q

What is the etiology of primary peritonitis?

A
  • Enterobacteriaceae (63%)
  • S. pneumoniae (15%)
  • Enterococci (6-10%)
  • Anaerobes (<1%)
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21
Q

What is the treatment of primary peritonitis

A
  • FQ (fluoroquinolones)
  • 3rd generation of cephalosporines (cefotaxime, ceftriaxone)
  • pip/tazo, amp/sulb
  • carbapenems
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22
Q

What is the most common etiology of primary peritonitis?

A

Enterobacteriaceae

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23
Q

What is the etiology of secondary peritonitis?

A
  • Enterobacteriacea
  • Bacteroides
  • Enterococci
  • P. aeruginosa
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24
Q

What is the treatment of secondary peritonitis?

A
  • pip/tazo, amp/sulb

- carbapenems

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25
Q

Peritonitis - clinical symptoms:

A
  • Abdominal pain
  • Loss of appetite
  • Fever (>38 °C)
  • Abdominal distension and tenderness
  • Silent bowel sounds and slow peristalsis
  • Paralytic ileus
  • Leucocytosis
  • High levels of CRP
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26
Q

Peritonitis - Diagnosis:

A
  • Blood tests
  • Imaging tests (X-Ray/CT scan- perforation, ileus,…)
  • Peritoneal fluid analysis (diagnostic paracentesis)
  • Microbiological examination
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27
Q

Peritoneal fluid analysis (Exudate):

A
  • WBC > 250 cells/mm3

- Protein > 3 g/dl

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28
Q

Primary Peritonitis - other facts:

A
  • Relatively infrequent
  • 25% with ALD (cirrhosis)
  • 60% of patients on chronic ambulatory peritoneal dialysis (CAPD)
  • Catheter connecting abdominal cavity to exterior body is a major risk factor
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29
Q

Appendicitis - Highest incidence:

A
  • 10-19 y/o,

- male>female

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30
Q

What happens when we have obstruction within the appendix?

A

Obstruction within appendix -> inflammation -> occlusion of vascular and lymphatic flow -> bacterial overgrowth -> necrosis

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31
Q

What are the symptoms of appendicitis?

A
  • non-localized pain in early stage
  • then pain in the right lower quadrant of abdomen
  • tenderness
  • slower peristalsis (silence)
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32
Q

What are the general symptoms of appendicitis?

A
  • fever
  • leucocytosis >15 G/l
  • high levels of CRP
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33
Q

Appendicitis - treatment - Acute, non-perforated:

A

cephazolin + metronidazole

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34
Q

Appendicitis - treatment - Perforated:

A
  • 2nd, 3rd generation of ceph

- or FQ + metronidazole; pip/tazo; imipenem

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35
Q

When should the antibiotics for appendicitis be given when it comes to surgery?

A

Antibiotics should be started before surgery, continued for 7 to 10 days

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36
Q

How should the treatment of appendicitis be given?

A

Switch to oral antibiotics when possible

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37
Q

Intra-abdominal abscess:

A

a pyogenic abscess (pus-filled cavity) may be caused by an infection due to illness or trauma

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38
Q

Pyogenic abscess:

A

pus-filled cavity

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39
Q

What is an abscess:

A

purulent collection of fluid, necrotic debris, bacteria, inflammatory cells that is encapsulated by healthy cells in an attempt to keep pus from infecting neighboring structures

40
Q

What causes an intra-abdominal abscess?

A

Result of chronic inflammation

- develop over days/months

41
Q

Where is an intra-abdominal abscess located?

A

Located within peritoneal cavity or visceral organs

42
Q

What is the volume of an intra-abdominal abscess?

A

may range from a few milliliters to a liter in volume?

43
Q

What is generally the etiology of an intra-abdominal abscess?

A

Usually mixed infection: aerobs and anaerobs within the same abscess

44
Q

What is, more specifically, the etiology of an intra-abdominal abscess?

A
  • E. coli
  • K. pneumoniae
  • Enterococci
  • B. fragilis
  • Clostridium
45
Q

What are the symptoms of intra-abdominal abscess?

A
  • Low grade fever
  • Abdominal pain/ discomfort
  • Abdominal distension
46
Q

What is the lab results of intra-abdominal abscess?

A
  • leucocytosis

- positive blood cultures

47
Q

What is the radiological examinations for intra-abdominal abscess?

A
  • USG
  • CT
  • MRI
48
Q

What is the result of a ruptured intra-abdominal abscess?

A

Ruptured abscess -> spreading bacteria and toxins into systemic circulation -> peritonitis/sepsis/MOF

49
Q

what is the treatment of intra-abdominal abscess?

A
  • Surgery (drainage or debridment, resection of perforated colon, small intestine, etc.)
  • Antimicrobial therapy
  • Support of vital function
50
Q

Intra-abdominal abscess - treatment - Aerobic activity:

A
  • Aminoglycosides
  • beta-lactams (ceftriaxone, cefotaxime)
  • FQ
  • Vancomycin/linezolid (Enterococci, MRSA)
  • carbapenems
51
Q

Intra-abdominal abscess - treatment - Anaererobic activity:

A
  • Metronidazole

- clindamycin

52
Q

Broad spectrum antibiotics can change the normal GI flora:

A
  • Increases in Candida or Gram negative bacteria
  • Proliferation of antibiotic resistant organisms
  • Pseudomembranous colitis from over proliferation of toxin producing anaerobe, Clostridium difficile
53
Q

Antibiotic Associated Diarrhea causes:

A

1) Antibiotic therapy (broad spectrum agents: clindamycin, ampicillin, 3rd generation cephalosporins are most common)
2) Disruption of normal colonic flora
3) C. difficile colonization
4) Release of toxins A (enterotoxin) and B (cytotoxin)
5) Damage to colonic mucosa, inflammation, intestinal fluid secretion

54
Q

What are the most common antibiotic agents that cause antibiotic associated diarrhea?

A

broad spectrum agents:

  • clindamycin
  • ampicillin
  • 3rd generation cephalosporins
55
Q

Toxins A =

A

enterotoxin

56
Q

Toxin B =

A

cytotoxin

57
Q

Pseudomembranous colitis - spectrum of diseases:

A
  • Colitis

- Pseudomembranous colitis

58
Q

Colitis - symptoms:

A
  • malaise
  • abdominal pain
  • watery diarrhea
  • nausea
  • low fever
59
Q

Pseudomembranous colitis - symptoms:

A
  • severe abdominal pain
  • perfuse diarrhea
  • high fever
60
Q

C. difficile risk if antibiotics……

A

C. difficile risk if antibiotics were used in past 2 months

61
Q

Pseudomembranous colitis - diagnosis:

A

stool culture of C. difficile presence of toxin A, B; endoscopy

62
Q

Pseudomembranous colitis - treatment - First line:

A

Metronidazole
Dose: 3 x 500 mg PO per day x 10-14 days

Always stop the drug responsible for causing the infection as soon as possible!!!

63
Q

Pseudomembranous colitis - treatment - Alternative:

A

Vancomycin

Dose: 4 x 250 mg PO x 10-14 days

64
Q

When do we give vancomycin to treat Pseudomembranous colitis?

A

if not responding to metronidazole or recurrence

65
Q

IAI management:

A

Surgical intervention + Antimicrobial therapy

66
Q

IAI - What first?

A
  • Initial Diagnostic
  • Fluid Resuscitation
  • Timing of Initiation of Antimicrobial Therapy
  • Elements of Appropriate Intervention
  • Microbiologic Evaluation
67
Q

Initial Diagnostic Evaluation:

A
  • Routine history, physical examination, and laboratory studies are sufficient to identify most patients
  • Those with an obtunded mental status or spinal cord injury or those immunosuppressed by disease or therapy, IAI should be considered if the patient presents with evidence of infection from an undetermined source
68
Q

Routine history, physical examination, and laboratory studies are sufficient to identify most patients:

A
  • characteristic abdominal pain
  • localized abdominal tenderness
  • laboratory evidence of acute inflammation
69
Q

IAI - Initial Diagnostic Evaluation - imaging:

A
  • Imaging is unnecessary, if immediate surgical intervention is to be performed
  • otherwise CT scan is the imaging of choice to determine the presence of an intra-abdominal infection and its source
70
Q

What is the imaging of choice to determine the presence of an intra abdominal infection and its source?

A

otherwise CT scan is the imaging of choice to determine the presence of an intra abdominal infection and its source

71
Q

Fluid Resuscitation:

A

rapid restoration of intravascular volume

72
Q

Fluid Resuscitation - septic shock patients:

A

for patients with septic shock, such resuscitation should begin immediately when hypotension is identified

73
Q

Fluid Resuscitation - or patients without evidence of volume depletion:

A

for patients without evidence of volume depletion, intravenous fluid therapy should begin when the diagnosis of intra-abdominal infection is first suspected

74
Q

IAI - Antimicrobial therapy should be initiated:

A
  • once a patient receives a diagnosis or IAI is considered likely
  • for patients with septic shock as soon as possible
  • for patients without septic shock, at least to start in the emergency department
  • always when a source control intervention is planned
75
Q

Mild-to-moderate community-acquired infection in adults:

A

Should be active against:

  • enteric gram-negative aerobic
  • facultative bacilli
  • enteric gram-positive streptococci

Not recommended:

  • Ampicillin/sulbactam E.coli resistance
  • Cefotetan and clindamycin B.fragilis resistance
  • Aminoglycosides - toxic
76
Q

High-risk community-acquired infection in adults:

A

Should include:
- broad-spectrum antibiotics with activity against gram negative organisms

Not recommended:

  • agents effective against methicillin-resistant S. aureus (MRSA) or yeast, unless there is evidence of infection with such organisms
  • quinolones should not be used unless hospital surveys indicate more than 90% susceptibility of E. coli to these agents
77
Q

Acute peritonitis WHO recommendations - treatment:

A
  • AMPICILLIN 2g i.v. or i.m. every 6 hours for at least 7 days

PLUS

  • GENTAMICIN 5-7mg/kg i.v. daily in divided doses for at least 7 days

PLUS

  • METRONIAZOLE 500mg i.v. every 8-12 hours for at least 7 days (contraindicated during pregnancy).
78
Q

When is metronidazole contraindicated?

A

metronidazole is contraindicated during pregnancy

79
Q

Cholecystitis and cholangitis in adults - treatment:

A
  • Anaerobic therapy is not indicated unless a biliary enteric anastomosis is present
  • Antibiotic treatment should be initiated ASAP and stopped 24h after cholecystectomy
80
Q

C. albicans - treatment:

A

fluconazole

81
Q

Resistant C. albicans - treatment:

A

echinocandin (eg. Caspofungin)

82
Q

What treatment do we give critically ill patients:

A

echinocandin should be the initial treatment in critically ill patients

83
Q

When is echinocandin used?

A
  • initial treatment in critically ill patients

- when there is resistant C. albicans

84
Q

Empiric anti-enterococcal therapy is recommended:

A
  • in patients with health care-associated intra-abdominal infection
  • who have previously taken cephalosporins or other antimicrobial agents selecting for Enterococcus species
  • in immunocompromised patients
  • in those with valvular heart disease or prosthetic intravascular materials
  • should be directed against E. faecalis (ampicillin, piperacillin /tazobactam, vancomycin)
  • for vancomycin-resistant E. faecium is NOT recommended
85
Q

Who should get anti-MRSA therapy?

A
  • to patients with health care-associated IAI who are colonized with the organism
  • who are at risk of infection because of previous treatment failure and antibiotic exposure
  • Vancomycin is recommended for both suspected or proven MRSA IAI
86
Q

Elements of Appropriate Intervention:

A
  • Drain infected foci
  • Control ongoing peritoneal contamination
  • Restore anatomic and physiologic function
  • Intervention may be delayed for up to 24 hours in closely monitored patients who have started antimicrobial therapy
87
Q

Microbiologic Evaluation:

A
  • In community-acquired IAI - blood cultures or Gram stain are not routinely recommended
  • For health care-associated IAI, Gram stains may help define the presence of yeast
88
Q

Microbiologic Evaluation - For higher-risk patients:

A

For higher-risk patients, cultures from the site of infection should be routinely obtained, particularly in patients with prior antibiotic exposure, who are more likely than other patients to harbor resistant pathogens

89
Q

Microbiologic Evaluation - cultures:

A
  • from 1 specimen
  • at least 1 ml of fluid or tissue (preferably more)
  • transported to the laboratory in an appropriate transport system
90
Q

SBP =

A

Spontaneous Bacterial Peritonitis

91
Q

Spontaneous Bacterial Peritonitis (SBP) - who usually gets it:

A

almost exclusively in people with portal hypertension

92
Q

Spontaneous Bacterial Peritonitis (SBP) - symptoms and manifestation:

A
  • patients may complain of abdominal pain and worsening ascites
  • hepatic encephalopathy may be the only manifestation of SBP
93
Q

Spontaneous Bacterial Peritonitis (SBP) - diagnosis:

A

the diagnosis of SBP requires paracentesis

94
Q

When is Spontaneous Bacterial Peritonitis (SBP) confirmed:

A

confirmed if the fluid contains bacteria or neutrophil granulocytes >250 cells/μL

95
Q

Spontaneous Bacterial Peritonitis (SBP) - treatment

A
  • cefotaxime 2g IV Q8-12h for at least 5 days

or

  • ceftriaxone 2g IV Q24h
96
Q

Clinical Factors Predicting Failure of Source Control for Intra-abdominal Infection

A
  • Delay in the initial intervention (24 h)
  • High severity of illness (APACHE II score 15)
  • Advanced age
  • Comorbidity and degree of organ dysfunction
  • Low albumin level
  • Poor nutritional status
  • Degree of peritoneal involvement or diffuse peritonitis
  • Inability to achieve adequate debridement or control of drainage
  • Presence of malignancy

Infectious Diseases (4th year) (19 decks)

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