A Focus on Intra Abdominal Infections

Ajeng Tribawati , dr Juli 2010

A Focus on Intra-Abdominal Infections

A journal review by Massimo Sartelli Published : March, 19. 2010 Sartelli World Journal of Emergency Surgery 2010, 5:9 http://www.wjes.org/content/5/1/9

Background
Complicated intra-abdominal infections are an

important cause of morbidity and are frequently associated with poor prognosis, particularly in higher risk patients. Despite advances in diagnosis, surgery, antimicrobial therapy mortality associated with complicated intra-abdominal infections remains still unacceptably high. Factors consistently associated with poor outcomes in patients with intra-abdominal infections include increased illness severity, failed source control, inadequate empiric antimicrobial therapy and healthcare-acquired infection.

Intra Abdominal Infections (IAIs)

S u rg ica l re se ctio n or A n tib io tics

Source control and Antibiotics

They are characterized by : creased mortality because of both underlying patient health status creased likelihood of infection caused by multi drugs resistant organism

Prognostic Evaluation
advanced age poor nutrition pre-existing diseases Immunodepression extended peritonitis occurrence of septic shock poor source control organ failures prolonged hospitalization before therapy infection with nosocomial pathogens

Scoring Systems

Billing et al. 2003. 7 centres in Europe. Realibility of MPI

*) treshold index 26, sensitivity 86 %, specificity 74 %, accuracy on death 83 %

MPI score < 21 21 29 > 29

Mortality Rate (%) 2,3 22,5 59,1

sy and reliable means of risk evaluation and classification fo

0 beats per minute , respiratory rate > 20 breaths per minute ( not ventilated )

dominal infection source in septic patients depends on the

UNSTABLE Px

Ultrasound

STABLE Px

CT SCAN

diagnostic study of choice for intra-abdominal infections. CT can detect small q

Ultrasound (US) / USG

RUQ : Perihepatic abcess, Cholecystitis,

pancreatitis RLQ & pelvic : Appendicitis, Tubo ovarian abcess, Douglass abcess Advantage : portable Limited because of : - Patient discomfort - Abdominal distension - Bowel gas interference

Doria et al. A meta-analysis Evaluated Diagnostic Performance of US and CT

Population Children Devices Ultrasound CT Adults Ultrasoud CT Sensitivity 88 % 94 % 83 % 94 % Specificity 94 % 95 % 93 % 94 %

ty perspective consideration : the radiation of CT , especially in chil

CT has a significantly higher sensitivity than US .

Source ControL
All measures undertaken to eliminate the

source of infection and to control ongoing contamination Most common source :

1.Appendix 2.Colon 3.The stomach

Early control can be achieved either by non

operative or operative means

The choice of procedure depends on :

1.The 2.The 3.The 4.The

anatomical source of infection degree of peritoneal inflammation generalized septic response patients general conditions

The main purpose : 1.To establish the cause of peritonitis 2.To control the origin of sepsis

Non Opx Interventional Procedures

Percutaneous Drainages of Abscesses Safe and effective Studies : cure rates of 62 % 91 %, morbidity and mortality rates surgical drainage Failure caused by : - misdiagnosis of the magnitude - extent - complexity - location of the abcess

*) with temporarily abdomen closure or open abdomen

The aim in the planned laparotomy is to perform every 36 to 48 hours inspection, drainage, and peritoneal lavage of the abdominal cavity. It is performed eitherwith temporarily abdomen closure or open abdomen. The aim in the on-demand laparotomy is to perform reoperation only in those patients who may benefit from it. The final decision to perform a reoperation on a patient in the ondemand setting is generally based on patients generalized septic response and lack of clinical improvement. Currently, there is no consensus on which criteria may be used to undergo relaparotomy.

Antimicrobial Therapy in IntraAbdominal Infections

It is appropriate to begin empiric antimicrobial

therapy before an exact diagnosis is established and before results of appropriate cultures are available. Since the causative pathogens can easily be predicted in community acquired infections, bacteriological diagnosis is not necessary.

Complicated IAIs are related to bowel perforation and contamination with its flora
Location Upper GI tract Lower GI tract Colon
Number of bacterias What kinds of bacterias?

103 to 105 bacteria/mL 101113 bacteria/mL

Gram + , Gram aerobic, facultative Gram facultative, organisms aerobic organisms Facultative & obligate anaerobic organisms, Gram facultative organisms

The medical antecendents given can affect the normal flora . be colonized by altered flora including multidrug - resistant nosocomia

Many factors can contribute to a patients risk for isolation of resistant pathogens. These include: Health care-associated infections High severity of illness (APACHE II score >15) Advanced age Comorbidity and degree of organ dysfunction Poor nutritional status and low albumin level Immunodepression Presence of malignancy

Multidrug Resistant Pathogens

Organisms Resistancy Enterococcus Penicillins, Cephalosporins, Methicillin Resistant Extended Penicillins, 1st , Staphylococcus 2nd , 3rd Spectrum Aureus (MRSA) Cephalosporins, Lactamases (ESBLs) Aztreonam producing Enterobacterice ae Risk Factors Antimic. Agents Post operative Carbapenems, /nosocomial infx, Fluoroquinolones HA-IAIs Quinupristin/Dal recent exposure , prolonged hospital fopristin, Carbapenems, stays + invasive med. to broad spec AB Daptomycin, Tigecycline devices. NGT, eg. gastrostomy/jejunosto Linezolid, Cephalosporins my tubes, arterial line, Tigecicline
TPN, recent surgery, hemodialysis, decubitus ulcers, poor nutritional status

Organisms Pseudomonas aeruginosa Acinetobacter baumannii Bacteroides Fragilis

Resistancy

Risk Factors ICU patients, HA-IAIs

Clindamycin, Moxifloxacin

Antimic. Agents Carbapenems, Amikacin, Carbapenems, Piperacillin/Tazo Aminoglycosides bactam, Imipenem, (Amikacin/Gentamicin), Ceftazidime, PiperacillinTetracyclines Cefepime, Tazobactam, ), (Minocycline/Doxycycline Fluoroquinolones Metronidazole Sulbactam , Aminoglycosides , Aztreonam, Polymyxin B & E

Organisms Candida

Resistancy Risk Factors Antimic. Agents Broad spec AB Broad spec AB, Fluconazole, CV cathetetrs, Caspofungin, PN, renal Anidulafungin, replacement tx Micafungin by px in ICU, neutropenia, immunosuppresi ve agents (glucocorticosteroids, chemotx, immunomodulators)

Conclusion
Early prognostic evaluation of complicated

intra-abdominal infections is important to select high-risk patients for more aggressive therapeutic procedures. The cornerstones in the management of complicated intra-abdominal infections are both source control and antibiotic therapy. Timing and adequacy of source control is the most important issue in the management of intra-abdominal infections, because an inadequate and late operation may have a negative effect on outcome.