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S2B1: Pharmacology > Treatment of Abdominal Infections > Flashcards

Treatment of Abdominal Infections Flashcards

1
Q

What is the usual cause of intra-peritoneal infections?

What are the two stages of intra-peritoneal infections?

What should occur once an intra-abdominal infections is suspected?

A

normal anatomic barrier is disrupted

2 stages

  1. peritonitis
  2. abscess formation
  • antimicrobial therapy should begin immediately
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2
Q

How commonly do intra-abdominal infections cause mortality in the ICU?

A

second most common cause of infectious mortality in intensive care units

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3
Q

Empiric regimens for intra-abdominal infections includ antimicrobial activity against which agents?

What are indications that a broader antimicrobail coverage is needed?

A
  • Agents
    • enteric streptocci
    • coliforms (Escheria, Klebsiella, Proeus, Enterobacter)
    • anaerobes
  • Indications broader coverage
    • community vs health-care acquired
    • travel history in areas with resistant organisms
    • co-morbidities or complicating factors
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4
Q

What risk factors warrant broad empiric antimicrobial covnerage for intra-abdominal infetions?

A
  • Factors associated with mortality
    • age > 70
    • medical comorbidity (liver disease, malignancy, chronic malnutrition)
    • Immunocompromising condition
    • High severity of illness
    • Extensive peritoneal involvement or diffuse peritonitis
    • Delay in initial intervention (source control) > 24hr
    • Inability to achieve adequate debridement or drainage control
  • Factors associated with infection with antibiotic-resistant bacteria
    • healthcare-acquired infection
    • trace to areas w/ higher rates antibiotic-resistant organisms within few weeks prior to infection onset or if antiobiotics were received during travel
    • known colonization with antibiotic-resistant organisms
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5
Q

What steps are critical to the managemetn of intra-abdominal infections other than spontaneous peritonitis?

Why?

A

Surgical intervention and/or precutaneous drainage other than spontaneous peritonitis

allows direct collectin of samples for microbiologic analysis

most clinical treatements failures are duet to failure to achieve suc source control

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6
Q

Emperic regimen for low-risk community acquired intrabdominal infections in adults?

Single-agent and combination

A
  • Single
    • Ertapenem
    • Piperacillin-tazobactam
  • Combination regimen with metronidazole
    • One of the following:
      • cefazolin
      • cefuroxime
      • cefrtiaxone
      • ceftaxime
      • ciprofloxacin
      • levofloxacin
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7
Q

Emperic regimen for high-risk community acquired intrabdominal infections in adults?

Single-agent and combination

A
  • Single agent
    • imipenem-cilastin
    • meropenem
    • doripenem
    • piperacillin-tazobactam
  • Combination with metronidazole
    • ONE of the following:
      • cefepime
      • ceftazidime
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8
Q

Emperic regimen for healthcare associated intrabdominal infections in adults?

Single-agent and combination

A
  • single agent
    • imipenem-cilastin
    • meropenem
    • doripenem
    • piperacilin-tazobactam
  • combination therapy
    • ONE of the following
      • cefepime
      • ceftazidime
    • PLUS
      • metronidazole
    • PLUS ONE of the following (in some cases)
      • ampicillin
      • vancomycin
    • If patient does not tlerate beta lactams or cephalosporins
      • vancomycin, aztreonam and metronidazole
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9
Q

What etilogical agents are being covered in empiric coverage of primary peritonitis?

When should therapy be narrowed?

A
  • gram negative aerobic bacilli and gram positive cocci
    • 3rd generation cephalosporin
    • broad spectrum penicillin/beta lactamase inhibitor combo
  • once organisim is identified, therapy should be narrowed
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10
Q

What antibiotics are used for prophylaxis for recurrence of primary peritonitis?

What percent of patience experience a recurrance?

What is the risk with long-term antibiotic usage?

A
  • Prophylaxis
    • fluoroquinalones (ciprofloxacin, norifloxacin)
    • trimethoprim-sulfametoxazole
  • 70%; w/ prophylaxis decreases to < 20%
  • can increase the risk of severe staphylococcal infections
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11
Q

When does secondary peritonitis develop?

What is the prophylaxis regimen to prevent secondary peritonitis?

A
  • when bacteria contaminate th eperitoneum as a result of spillage from an intraabdominal viscus
  • prophylaxis
    • gram negative aerobic and anaerobes
    • borad spectrum penicillin/beta lactamase inhibitor combinations (ticaracillin/clavulante)
    • OR combo with metronidazole
      • PLUS
      • fluroquinalone (levofloxacin)
      • 3rd generation cephalosporin (cefotaxime)
    • if in ICU, require
      • imipenem
      • meropenem
      • combo that will treat most likely infecting agent
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12
Q

Why is antimicrobial therapy usually done in association with surgery?

A

to treat early bacteremia, decrease incidence of abscess formation and wound infection, and to prevent distant spread of infection

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13
Q

Empiric coverage for continuous ambulatory peritoneal dialysis (CAPD) should be aimed at what etilogical agents?

Antibiotic regimen?

A
  • Agents
    • S. aureus
    • coagulase-negative staphylococcus
    • gram negative bacilli
  • Treatment
    • first generation cephalosporin (cefazolin)
    • AND
    • fluroquinalone
    • OR
    • third generation cephalosporin (ceftazidime)
    • In areas with high incidence of MRSA, Vancomycin should be added
      • toxic patients & those with exit site infections
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14
Q

In what conditions is empirc therapy usualy successful for low-risk community acquired ifnections?

A

if E. coli susceptibility is >90% and no resistand organisms

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15
Q

What steps are critical to the management of intra-peritoneal abscess?

A
  • determination of the initial focus of infection
  • perform a drainage procedure if one or more definitive avscesses have formed
  • administration broad spectru antibiotics targeting the organisms involved
    • gram negative aerobic, facultative, and anaerobic
    • broad spectrum penicillin/beta lactamase inhibitor combination
    • OR
    • combination with metronidazole
      • fluroquinalone
      • OR
      • 3rd generation cephalosporine (ceftaxamine)
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16
Q

How is targerted antimicrobial therapy chose for intraperitoneal abscess?

This still must cover which classes of microbes?

A
  • chosen based on results of culture adn susceptibility testing from appropriate specimen
  • Cover coliforms and anaerobes
    • anaerobic component is often not determine but is assumed & treated empiracally even when they are not isolated from the culture
17
Q

Describe the differences in treatment for the different visceral abscesses: liver, splenic, periphrenic and renal

A
  • liver
    • drainage is mainstay of therapy
    • broad spectrum penicillin/beta lactamase inhibitor combinations
    • combination metronidazole
      • PLUS fluroquinalone
      • OR
      • 3rd generation cephalosporin (cefotaxime)
    • antibiotics are adjusted when cultures are available
  • splenic
    • splenectomy wiht adjunctive antibiotics has traditionally be standard care
      • vaccinated against encapsulated organisms
        • Streptococcus pneumoniiae, Haemphilus influenzae, Neisseria meingitidis
    • early diagnosis is most important factor
  • periphrenic and renal
    • drainage with adjunctive antibiotic therapy directed at the infecting organism
18
Q

Fill out the summary table for treatment of infections/abscesses

A
19
Q

What is an antibiogram?

A

Done at hospitals and nursing homes

List the species that are present in any given institution & primary and secondary antibiotic and give you a percent of isolates that are susceptible to those antibiotics at any given period of time

Helps with decision-making process for starting emperic therapy

20
Q

What percent of travelers are affected by travelers diarrhea?

What is the usual cause?

Is prophylaxis recommended?

A
  • Very predictable, 30-70% travelers are affected
  • local restaurant poor hygeine is most likely cause
  • prophylaxis is generally not recommended
    • use of bismuth subsalicylate can be effective but cumbersome to carry (multiple daily doses)
21
Q

General treatment Traveler’s Diarrhea?

Special considerations?

A
  • largly empiric
  • if severe, rehydration is crucial
    • oral, if necessary, IV
  • Loperamide
    • symptomatic relief – use with caution in patients w/ dysentery
    • avoid in patients with possible C difficle (those taking prophylactic antibiotitcs) b/c risk toxic megacolon
  • Antimotility agents can prolong duration some enteric infections such as shigellosis
    • indiscriminate use of these agens can also cause increased incidence of more severe problems, such as toxic megacolon, sepsis, and disseminated intravascular coagulation
    • should NOT be used with fever or bloody diarrhea
22
Q

Effective antibiotic therapy for traveler’s diarrhea must do what?

What has become a problem with antibiotic therapy?

Recommended regimen?

A
  • effective antibiotiv therapy reduces the duration of enterotoxigenic E coli (ETEC) and enteraggresateive E coli (EAEC), the most common cause of traveler’s diarrhea
  • antibiotic resistance is a major probem and has reduced the efficacy of
    • trimethoprim-sulfamethoxazole,
    • aminopenicilins
    • tetracyclines
  • Recommended NOW
    • fluorquinalones
    • azithromycin
  • b/c Rifaximin is effective against ETEC, may become next epmiric treatment for nondysenteric traveler’s diarrhea
23
Q

Identify the suggested therapy for the following traveler’s diarrhea clinical situations:

  • watery diarrhea (no blood in stool, no fever), 1 or 2 unformed stool per day without distressing enteric symptoms
  • Watery dairrhea (no blood in stool, no fever) 1 or 2 unformed stools per day with distressing enteric symptoms
  • Watery diarrhea (no blood in stool, no distressing abdominal pain, no fever), >2 unformed stools per day
  • Dysentery (passage bloody stool) or fever (>37.8 degrees C)
  • Vomiting, minimal diarrhea
  • DIarrhea in infants (<2 years old)
  • Diarrhea in pregnant women
A
  • watery diarrhea (no blood in stool, no fever), 1 or 2 unformed stool per day without distressing enteric symptoms
    • oral fluids and saltine crackers
  • Watery dairrhea (no blood in stool, no fever) 1 or 2 unformed stools per day with distressing enteric symptoms
    • Bismuth subsalicylate (for adults) or loperamide for 2 days
  • Watery diarrhea (no blood in stool, no distressing abdominal pain, no fever), >2 unformed stools per day
    • antibacterial drug plus (for adults) loperamide
  • Dysentery (passage bloody stool) or fever (>37.8 degrees C)
    • antibacterial drug
      • fluroquinalone, azythromycin, or rifaximin for adults
      • azithromycin or furazolidone for children
      • plus oral fluids and saltine crackers
  • Vomiting, minimal diarrhea
    • bismuth subsalicylate (for adults)- 2 days
  • DIarrhea in infants (<2 years old)
    • fluids and electrolytes; continue feeding adn seek medical attention for
      • moderate dehydration, fever lasting >24 hrs., bloody stool or diarrhea lastign more than a few days
  • Diarrhea in pregnant women
    • fluids and electrolytes
    • can consider attapuligite
    • seek medical attention for persistent or sever symptoms
24
Q

Identify the suggested therapy for traveller’s diarrhea in the following clinical situations

  • Diarrhea despite trimethoprim-sulfamethoxazole prophylaxis
A

Fluroquinolone - with lopermide if no fever adn no blood in stool, alone in cases of fever/dysentery

25
Q

Identify the suggested therapy for traveller’s diarrhea in the following clinical situations

  • Diarrhea despite fluroquinolone prophylaxis
A

bismuth subsalicylate for milde to moderate disease; consult physician for moderate to sever disease or if disease persists

26
Q

How many Americans are infected wtih Clostridiodes difficle each year?

fatalities?

Treatment types?

A
  • infected
    • half a million
  • fatalities
    • 14,000
  • treatments
    • antibiotic therapy
    • fecal transplants
27
Q

What antimicrobial agents are frequently associated with causing C. diff infection?

occationally associated?

rarely associated?

A
  • Frequently associated
    • fluroquinolones
    • Clindamycin
    • Cephalosporins (broad spectrum)
    • Penicillins
  • Occasionally associated
    • macrolides
    • trimethoprim-sulfamethoxazole
  • Rarely associated
    • Aminoglycosides
    • Tetracyclines
    • Metronidazole
    • Vancomycin
28
Q

What is the first step in treatment of C. diff infection?

A

placebo or discontinuation of offending antibiotics

29
Q

Treatment of thee initial infection of C. diff causing nonsevere disease (WBC <15,000 cells/mL and serum creatine <15 mg/dL)

Severe disease? (WBC >15,000 cells/mL and/or serum creatinine >1.5 mg/dL)

Fulimant disease (hypotension or shock, ileus, megacolon)

A
  • nonsevere
    • vancomycin (orally)
    • OR
    • Fidaxomicin (orally)
    • if above agents not available
      • metronidazole (orally)
  • severe
    • vancomycin (orally)
    • OR
    • Fidaxomicin (orally)
  • fulminant
    • enteric vancomycin + parental perenteral metronidazole
    • if ileus present
      • rectal vancomycin as retention enema
30
Q

Treatment of recurrent infection of C. diff

  • first recurrence (nonsevere and severe)
  • second or subsequent (nonsevere and severe)
A
  • first recurrence
    • if vancomycin used initial episode
      • vancomycin pulsed-tapered regimen
      • OR
      • fidaxomicin (orally)
    • if fidaxomicin or metranidazole was used in initial episode
      • vancomycin (orally)
  • second or subsequent recurrence
    • vancomycin pluse tapered regimen
    • OR
    • fidaxomicin
    • OR
    • vancomycin followed by rifaximin
    • OR
    • FMT
31
Q

What are the 3 nonantibiotic therapies for C. diff?

A
  1. Fecal bacteriotherapy
    • cure rates from 81-94%
    • particularily useful w/ patients with recurring severe disease
  2. Monoclonal antibodies
    • adjunctive use of monoclonal antibodies against C. difficiile toxins A and B (in addition to antibiotic therapy)
    • not available for routine clinical cases
  3. Probiotic therapy
    • studies are inconclusive

S2B1: Pharmacology (5 decks)

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