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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
What are the steps to manage IAI?
1. Source control -> surgery 2. Supportive care: hemodynamic stability, antipyretics, analgesics 3. Empiric antimicrobial -> de-escaltaiton to target therapy
26
Nonpharm for peritonistis?
Surgical intervention
27
What is used for hemodynamic resuscitation?
1. Fluids 2. Albumin
28
When is empiric antimicrobials initiated?
ASA IAI is suspected
29
What ABX is B. fragillis resistant to?
Clindamycin and cefotetan
30
What ABX is Enterobacter resistant to?
Ampicillin-sulbactam and FQ
31
Tx for PD SBP? Pathogen?
Vancomycin + cefipine or Ceftazidime Remove cath **Patho:** staph, strep, pseudomonas
32
Tx for cirrhosis SBP? Pathogen?
Ceftriaxone, Cefotaxime **Patho:** E. coli
33
When do you reassess SBP tx?
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
Prophylaxis agents for SBP?
1. BActrim DS QD 2. Ciprofloxacin QD
35
How are at risk for SBP recurrence?
1. Cirrhosis and GI bleeding 2. >1 epidode of SBP 3. Cirrhosis and ascites
36
Tx for Gastroduodenal secondary peritonitis?
Ceftriaxone
37
Tx for biliary tract secondary peritonitis?
Ceftriaxone
38
Tx for small or large bowel secondary peritonitis?
Ceftriaxone + Metronidazole OR Zosyn
39
Tx for appendicitis secondary peritonitis?
Ceftriaxone + Metronidazole OR Zosyn
40
Tx for abscesses secodnary peritonsisi?
Ceftriaxone + Metronidazole OR Zosyn
41
Tx for abscesses secodnary acute contamination from ab trauma?
Ceftriaxone + Metronidazole OR Zosyn
42
Pathogent for CA IAI?
**Mild-mod:** streptococci, non-resistant Enterobacteriaceae and anaerobes **High:** above + pseudomonas
43
Pathogen for HA IAI?
MRSA + Pseudomonas and resistant strain of enterobacter
44
RF of CA IAI?
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
Tx for low risk (mild-mod) CA IAI?
**Monotherapy:** * Zosyn * Meropenem (ESBL) * Moxifloxacin (anaerobic coverage) **Combo:** * Metronidazole + * Ceftriaxone, Cefotaxime, Cefuroxime (IV/PO) OR * Ciprofloxacin or Levofloxacin
46
Tx for high risk (severe) CA IAI?
**Monotherapy:** Zosyn **Combo:** Metronidazole + cefepime or ceftazidime
47
What specific pathogen makes the difference of empiric abx between low risk vs. high risk?
PA
48
HA IAI 2 agent tx?
- Add Vanc to high risk CA (Zosyn or Metronidazole + Cefepime or Ceftazidime) - Zosyn + Vanc - Meropenem + Vanc (ESBL suspicion)
49
HA IAI 3 agent tx?
Cefepime + metronidazole + Vancomycin **Or** Ceftazidime + metronidazole + Vancomycin
50
What is the duration of IAI tx?
**Peritonitis or IA abscess after adequate source control:** 4 days **Defintive source not possible:** 5-7 days **Acute IAI contamination:** 24 hrs
51
Montioring IAI tx?
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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