Antimicrobial approach to intra-abdominal infections in adults
- Miriam Baron Barshak, MD
Miriam Baron Barshak, MD
- Assistant Professor of Medicine
- Harvard Medical School
Infections within the abdominal cavity typically arise because of inflammation or disruption of the gastrointestinal tract. Less commonly, they can arise from the gynecologic or urinary tract. Abdominal infections are usually polymicrobial and result in an intra-abdominal abscess or secondary peritonitis, which may be generalized or localized (phlegmon).
The approach to antimicrobial selection and administration for intra-abdominal infections in adults is discussed here. The general and surgical management of these infections are discussed in detail elsewhere. (See "Management of acute appendicitis in adults" and "Acute colonic diverticulitis: Medical management" and "Acute colonic diverticulitis: Surgical management" and "Acute cholangitis" and "Treatment of acute calculous cholecystitis" and "Acalculous cholecystitis: Clinical manifestations, diagnosis, and management" and "Overview of gastrointestinal tract perforation".)
The approach to management of abscesses within specific intra-abdominal organs (such as the liver or kidney) are also discussed in detail separately. (See "Pyogenic liver abscess" and "Invasive liver abscess syndrome caused by Klebsiella pneumoniae" and "Renal and perinephric abscess" and "Management and complications of tubo-ovarian abscess" and "Posthysterectomy pelvic abscess".)
Spontaneous peritonitis and peritonitis associated with peritoneal dialysis are also discussed elsewhere. (See "Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis" and "Microbiology and therapy of peritonitis in continuous peritoneal dialysis".)
Intra-abdominal infections usually arise after a breach in the normal mucosal defense barrier that allows normal bowel flora to inoculate the abdominal cavity. The precise microbiological spectrum depends on the precise gastrointestinal source (ie, small versus large bowel).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Brook I, Frazier EH. Aerobic and anaerobic microbiology in intra-abdominal infections associated with diverticulitis. J Med Microbiol 2000; 49:827.
- Swenson RM, Lorber B, Michaelson TC, Spaulding EH. The bacteriology of intra-abdominal infections. Arch Surg 1974; 109:398.
- Brook I, Frazier EH. Microbiology of subphrenic abscesses: a 14-year experience. Am Surg 1999; 65:1049.
- Sabbaj J, Sutter VL, Finegold SM. Anaerobic pyogenic liver abscess. Ann Intern Med 1972; 77:627.
- Stone HH, Strom PR, Fabian TC, Dunlop WE. Third-generation cephalosporins for polymicrobial surgical sepsis. Arch Surg 1983; 118:193.
- Lucasti C, Jasovich A, Umeh O, et al. Efficacy and tolerability of IV doripenem versus meropenem in adults with complicated intra-abdominal infection: a phase III, prospective, multicenter, randomized, double-blind, noninferiority study. Clin Ther 2008; 30:868.
- Baughn AD, Malamy MH. The strict anaerobe Bacteroides fragilis grows in and benefits from nanomolar concentrations of oxygen. Nature 2004; 427:441.
- Bartlett JG, Onderdonk AB, Louie T, et al. A review. Lessons from an animal model of intra-abdominal sepsis. Arch Surg 1978; 113:853.
- Harbarth S, Uckay I. Are there patients with peritonitis who require empiric therapy for enterococcus? Eur J Clin Microbiol Infect Dis 2004; 23:73.
- Sitges-Serra A, López MJ, Girvent M, et al. Postoperative enterococcal infection after treatment of complicated intra-abdominal sepsis. Br J Surg 2002; 89:361.
- Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010; 50:133.
- Baron EJ, Miller JM, Weinstein MP, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clin Infect Dis 2013; 57:e22.
- Simor AE, Scythes K, Meaney H, Louie M. Evaluation of the BacT/Alert microbial detection system with FAN aerobic and FAN anaerobic bottles for culturing normally sterile body fluids other than blood. Diagn Microbiol Infect Dis 2000; 37:5.
- Wacha H, Hau T, Dittmer R, Ohmann C. Risk factors associated with intraabdominal infections: a prospective multicenter study. Peritonitis Study Group. Langenbecks Arch Surg 1999; 384:24.
- Torer N, Yorganci K, Elker D, Sayek I. Prognostic factors of the mortality of postoperative intraabdominal infections. Infection 2010; 38:255.
- Inui T, Haridas M, Claridge JA, Malangoni MA. Mortality for intra-abdominal infection is associated with intrinsic risk factors rather than the source of infection. Surgery 2009; 146:654.
- Woerther PL, Burdet C, Chachaty E, Andremont A. Trends in human fecal carriage of extended-spectrum β-lactamases in the community: toward the globalization of CTX-M. Clin Microbiol Rev 2013; 26:744.
- Peirano G, Laupland KB, Gregson DB, Pitout JD. Colonization of returning travelers with CTX-M-producing Escherichia coli. J Travel Med 2011; 18:299.
- Tham J, Odenholt I, Walder M, et al. Extended-spectrum beta-lactamase-producing Escherichia coli in patients with travellers' diarrhoea. Scand J Infect Dis 2010; 42:275.
- Tängdén T, Cars O, Melhus A, Löwdin E. Foreign travel is a major risk factor for colonization with Escherichia coli producing CTX-M-type extended-spectrum beta-lactamases: a prospective study with Swedish volunteers. Antimicrob Agents Chemother 2010; 54:3564.
- Röhrborn A, Wacha H, Schöffel U, et al. Coverage of enterococci in community acquired secondary peritonitis: results of a randomized trial. Surg Infect (Larchmt) 2000; 1:95.
- Ohlin B, Cederberg A, Forssell H, et al. Piperacillin/tazobactam compared with cefuroxime/ metronidazole in the treatment of intra-abdominal infections. Eur J Surg 1999; 165:875.
- Cohn SM, Lipsett PA, Buchman TG, et al. Comparison of intravenous/oral ciprofloxacin plus metronidazole versus piperacillin/tazobactam in the treatment of complicated intraabdominal infections. Ann Surg 2000; 232:254.
- Malangoni MA, Song J, Herrington J, et al. Randomized controlled trial of moxifloxacin compared with piperacillin-tazobactam and amoxicillin-clavulanate for the treatment of complicated intra-abdominal infections. Ann Surg 2006; 244:204.
- Brook I, Wexler HM, Goldstein EJ. Antianaerobic antimicrobials: spectrum and susceptibility testing. Clin Microbiol Rev 2013; 26:526.
- Goldstein EJ, Citron DM, Warren YA, et al. In vitro activity of moxifloxacin against 923 anaerobes isolated from human intra-abdominal infections. Antimicrob Agents Chemother 2006; 50:148.
- Prasad P, Sun J, Danner RL, Natanson C. Excess deaths associated with tigecycline after approval based on noninferiority trials. Clin Infect Dis 2012; 54:1699.
- FDA Drug Safety Communication: Increased risk of death with Tygacil (tigecycline) compared to other antibiotics used to treat similar infections. http://www.fda.gov/Drugs/DrugSafety/ucm224370.htm (Accessed on May 21, 2013).
- Wong PF, Gilliam AD, Kumar S, et al. Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults. Cochrane Database Syst Rev 2005; :CD004539.
- Goldstein EJ, Solomkin JS, Citron DM, Alder JD. Clinical efficacy and correlation of clinical outcomes with in vitro susceptibility for anaerobic bacteria in patients with complicated intra-abdominal infections treated with moxifloxacin. Clin Infect Dis 2011; 53:1074.
- Golan Y. Empiric therapy for hospital-acquired, Gram-negative complicated intra-abdominal infection and complicated urinary tract infections: a systematic literature review of current and emerging treatment options. BMC Infect Dis 2015; 15:313.
- Snydman DR, Jacobus NV, McDermott LA, et al. Update on resistance of Bacteroides fragilis group and related species with special attention to carbapenems 2006-2009. Anaerobe 2011; 17:147.
- Tally FP, Gorbach SL. Therapy of mixed anaerobic-aerobic infections. Lessons from studies of intra-abdominal sepsis. Am J Med 1985; 78:145.
- Lagacé-Wiens P, Walkty A, Karlowsky JA. Ceftazidime-avibactam: an evidence-based review of its pharmacology and potential use in the treatment of Gram-negative bacterial infections. Core Evid 2014; 9:13.
- Snydman DR, McDermott LA, Jacobus NV. Activity of ceftolozane-tazobactam against a broad spectrum of recent clinical anaerobic isolates. Antimicrob Agents Chemother 2014; 58:1218.
- Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med 2015; 372:1996.
- Livingston E, Vons C. Treating Appendicitis Without Surgery. JAMA 2015; 313:2327.
- Huang TS, Huang SS, Shyu YC, et al. A procalcitonin-based algorithm to guide antibiotic therapy in secondary peritonitis following emergency surgery: a prospective study with propensity score matching analysis. PLoS One 2014; 9:e90539.
- Jung B, Molinari N, Nasri M, et al. Procalcitonin biomarker kinetics fails to predict treatment response in perioperative abdominal infection with septic shock. Crit Care 2013; 17:R255.
- Quenot JP, Luyt CE, Roche N, et al. Role of biomarkers in the management of antibiotic therapy: an expert panel review II: clinical use of biomarkers for initiation or discontinuation of antibiotic therapy. Ann Intensive Care 2013; 3:21.
- SOURCE CONTROL AND DRAINAGE
- EMPIRIC ANTIMICROBIAL THERAPY
- - Low-risk community-acquired infections
- - High-risk community-acquired infections
- - Healthcare-associated infections
- TARGETED ANTIMICROBIAL THERAPY
- General principles of regimen selection
- - Assessment of culture data
- - Antibiotic stewardship
- - Anaerobic coverage
- - Parenteral versus oral therapy
- - Considerations for specific pathogens
- - Infectious disease consultation
- Duration of therapy
- CLINICAL FAILURE
- SUMMARY AND RECOMMENDATIONS