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Therapeutics IV > Intra-abominal Infection - Block 2 > Flashcards

Intra-abominal Infection - Block 2 Flashcards

1
Q

What is an intraabdominal infection?

A

Infection of peritoneum within peritoneal cavity or retroperitoneal space

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2
Q

GI flora in stomach?

A

Streptococcus
Lactobacillus

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3
Q

GI flora in biliary tract?

A

Normally sterile (E. coli, Klebsiella, or enterococci)

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4
Q

GI flora in proximal small bowel?

A

Strep, Enterococci, E. coli, Kleb, Lactobacillus, diphtheroids

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5
Q

GI flora in distal ileum?

A

E. coli, Kleb, Enterobacter, enterococci, Bacterides, Clostridium, peptostrep

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6
Q

GI flora in colon?

A
  • Enterobacteriaceae
  • Enterococci
  • anaerobes
  • candida
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7
Q

What is uncomplicated IAI?

A
  1. Affects a single organ
  2. Doesn’t spread to peritoneum
  3. No anatomic disruption of the GIT
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8
Q

What is complicated IAI?

A
  1. Extension of infection into peritoneal space
  2. May be contained/localized or cause diffuse peritonitis

The most common

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9
Q

Differentiate the types of peritonitis?

A

Primary: Spontaneous bacterial peritonitis (SBP)
Secondary: disruption of GIT, involve in polymicrobial infection
Tertiary: persists or recurs at least 48hrs after apparently adequate management of primary and secondary

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10
Q

What is the most common cause of primary peritonitis?

A

Alcoholic
Cirrhosis or ascites
PD

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11
Q

Pathogen associated with cirrhosis?

A

E. coli

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12
Q

Pathogen associated with PD?

A

Staph spp.
Sterptococcus
E. coli
Klebsiella
Pseudomonas

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13
Q

What are the causes of secondary peritonitis?

A

Breach of GI mucosal membrane due to:
1. Abscess
2. Polymicrobial infection

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14
Q

RF of developing candida infection?

A
  1. Extensive broad ABX
  2. Immunosuppressed patients
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15
Q

What are the common causes of secondary bacterial peritonitis?

A
  1. Diverticulitis
  2. Appendicitis
  3. IBD
  4. Billiary tract infection
  5. Intestinal obstruction
  6. Perforation
  7. Trauma
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16
Q

Pathogens assocaited with 2nd peritonitis?

A
  1. Strep
  2. E. coli
  3. Kleb
  4. Enterococci
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17
Q

RF for primary peritonitis?

A

PPI use

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18
Q

RF for secondary peritonitis?

A
  1. Advanced age
  2. Obesity
  3. Smoking
  4. Lack fo exercise
  5. Low fiber
  6. Gallstones
  7. Cholangitis
  8. Biliary tract colonization
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19
Q

S/s of primary peritonitis?

A

GI upset
Bowel sounds hypoactive
PD: clouding dialysate fluid

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20
Q

Lab of primary peritonitis?

A
  1. Mild elevated WBC
  2. Elevated Procal
  3. Fever
  4. Ascites fluid leukocytes >250
  5. Bacterial growth in ascites or dialysate
  6. Protein <1 -> hepatic impairment
  7. Glucose >50
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21
Q

S/s of secondary peritonitis?

A
  1. Quick onset of ab pain
  2. 3rd spacing
  3. Abdominal tenderness and distension
  4. Faint bowel sounds that cease over time
22
Q

Lab of secondary peritonitis?

A
  1. Elevated WBC
  2. Elevated BUN and lactate in hypovolemia
  3. Glucose <50
  4. Protein >1 -> protein leaking
  5. leukocytes >250
23
Q

Imaging used for IAI diagnosis?

A

Ultrasound: abscess
CT of abdomen and pelvis: identify foci of the infection
* Ascites in SBP
* Free air -> perforation

24
Q

Labs used to diagnosis IAI?

A

Microbio: culturing peritoneal fluid
CMP: WBC, Scr, liver enzyme, procalcitonin

25
Q

What are the steps to manage IAI?

A
  1. Source control -> surgery
  2. Supportive care: hemodynamic stability, antipyretics, analgesics
  3. Empiric antimicrobial -> de-escaltaiton to target therapy
26
Q

Nonpharm for peritonistis?

A

Surgical intervention

27
Q

What is used for hemodynamic resuscitation?

A
  1. Fluids
  2. Albumin
28
Q

When is empiric antimicrobials initiated?

A

ASA IAI is suspected

29
Q

What ABX is B. fragillis resistant to?

A

Clindamycin and cefotetan

30
Q

What ABX is Enterobacter resistant to?

A

Ampicillin-sulbactam and FQ

31
Q

Tx for PD SBP? Pathogen?

A

Vancomycin + cefipine or Ceftazidime
Remove cath

Patho: staph, strep, pseudomonas

32
Q

Tx for cirrhosis SBP? Pathogen?

A

Ceftriaxone, Cefotaxime
Patho: E. coli

33
Q

When do you reassess SBP tx?

A

5 day duration, reassess if:
1. PMN count is <250 cells/microL, treatment is stopped
2. PMN count is greater than the pretreatment value
3. PMN count is elevated but less than the pretreatment value continue ABX for another 48h, repeating paracentesis

34
Q

Prophylaxis agents for SBP?

A
  1. BActrim DS QD
  2. Ciprofloxacin QD
35
Q

How are at risk for SBP recurrence?

A
  1. Cirrhosis and GI bleeding
  2. > 1 epidode of SBP
  3. Cirrhosis and ascites
36
Q

Tx for Gastroduodenal secondary peritonitis?

A

Ceftriaxone

37
Q

Tx for biliary tract secondary peritonitis?

A

Ceftriaxone

38
Q

Tx for small or large bowel secondary peritonitis?

A

Ceftriaxone + Metronidazole
OR
Zosyn

39
Q

Tx for appendicitis secondary peritonitis?

A

Ceftriaxone + Metronidazole
OR
Zosyn

40
Q

Tx for abscesses secodnary peritonsisi?

A

Ceftriaxone + Metronidazole
OR
Zosyn

41
Q

Tx for abscesses secodnary acute contamination from ab trauma?

A

Ceftriaxone + Metronidazole
OR
Zosyn

42
Q

Pathogent for CA IAI?

A

Mild-mod: streptococci, non-resistant Enterobacteriaceae and anaerobes
High: above + pseudomonas

43
Q

Pathogen for HA IAI?

A

MRSA + Pseudomonas and resistant strain of enterobacter

44
Q

RF of CA IAI?

A
  1. > 70 YO
  2. Medical comorbidity
  3. Immunocompormised
  4. High severity of illness
  5. Extensive peritoneal or diffuse peritonitis
  6. Delay in initial intervention >24h
  7. Inability to achieve adequate debridement or drainage control
45
Q

Tx for low risk (mild-mod) CA IAI?

A

Monotherapy:
* Zosyn
* Meropenem (ESBL)
* Moxifloxacin (anaerobic coverage)

Combo:
* Metronidazole +
* Ceftriaxone, Cefotaxime, Cefuroxime (IV/PO) OR
* Ciprofloxacin or Levofloxacin

46
Q

Tx for high risk (severe) CA IAI?

A

Monotherapy: Zosyn
Combo: Metronidazole + cefepime or ceftazidime

47
Q

What specific pathogen makes the difference of empiric abx between low risk vs. high risk?

48
Q

HA IAI 2 agent tx?

A
  • Add Vanc to high risk CA (Zosyn or Metronidazole + Cefepime or Ceftazidime)
  • Zosyn + Vanc
  • Meropenem + Vanc (ESBL suspicion)
49
Q

HA IAI 3 agent tx?

A

Cefepime + metronidazole + Vancomycin
Or
Ceftazidime + metronidazole + Vancomycin

50
Q

What is the duration of IAI tx?

A

Peritonitis or IA abscess after adequate source control: 4 days
Defintive source not possible: 5-7 days
Acute IAI contamination: 24 hrs

51
Q

Montioring IAI tx?

A
  1. De-escalation ABX
  2. Renal daily
  3. WBC, fever, GI, ab pain
  4. Improvement within 48-72 hrs
  5. 4-7 days (recent studies shows 3-5 days no difference vs. 7 days) -> 4 days
  6. Abscess, follow up CT

Therapeutics IV (39 decks)

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