INTRA-ABDOMINAL INFECTION

A SURGICAL CHALLENGE

DR M.SHAMIM QURESHI
FCPS,FRCS (Eng)
PROFESSOR OF SURGERY
JINNAH POSTGRADUATE MEDICAL CENTRE
• Intra-abdominal infection is the common cause of
mortality & morbidity in I.C.U

• Appendicitis alone still affects 300,000 patients

per year and consume >1 million hospital days in
USA
De FrancesCJ,et all.Vital Health Stat 13 2007;165:1–209.

• Survival relies on
a. Early recognition
b. Timely targeted correction of root cause
c. Maintained ongoing organ support
IDSA GUIDELINES-2009
 MORTALITY OF INTRA-ABDOMINAL
INFECTIONS
60
50
40
30
20
10
0
 INTRA ABDOMINAL
INFECTION

COMPLICATED
UNCOMPLICATED
Peritonitis(localized,Diffuse)
Appendicitis,cholecystitis
 PERITONITIS
TYPES DEFINITION MICROBIOLOGY
Peritonitis due to bacterial Monomicrobial (gram –ve
translocation or Enterobacteraceae or
Primary hematogenous , lymphatic
seeding.
streptococci)

NO break in integrity of G.I

tract.

Peritoneal infection in Polymicrobial

conjunction with aerobic gram-ve bacilli,
Secondary inflammatory process of G.I
tract (microscopic/
gram+ve cocci
enteric anaerobes
macroscopic perforation)

Persistent or recurrent Nosocomial organisms

peritoneal infection after resistant gram-ve bacilli,
Tertiary initial treatment of secondary
peritonitis
enterococci
staphylococci
yeast
 IS THIS AN INFECTION?
HOW BAD THE INFECTION IS?
HISTORY Focus
Gastro intestinal dysfunction
EXAMINATION
SIRS
SEPSIS

SEVERE SEPSIS

SEPTIC SHOCK

INVESTIGATIONS Physiological derangement

 SEPTIC CARE BUNDLE
All emergency admissions have an early
warning score assessed on presentation, with
graded escalation policies for senior clinical
and intensive care unit (ICU)

HUDDART et al.BJS 2015

 ELEMENTS OF BUNDLE CARE
Broad-spectrum antibiotics to be given to all
patients with suspicion of peritoneal soiling or
with a diagnosis of sepsis .

Bjs2015;57-66
• Once the decision has been made to carry out
laparotomy, the patient takes the next
available place in the emergency theatre(or
within 6h of decision being made)

• Start resuscitation using goal-directed

techniques as soon as possible, or within 6h of
admission and admit all patients to i.c.u after
emergency laparatomy
Bjs-2015;57-66
 SEPSIS MANAGEMENT
DIAGNOSTIC
WORKUP

PATIENT
MONITORING RESUSCITATION

ORGAN SOURCE
SUPPORT CONTROL
 HISTORY
• FOCUS HISTORY

• PATIENT AGE /CO-MORBIDITIES

• HISTORY OF ANTIBIOTICS

• HISTORY OF HOSPITALIZATION & PREVIOUS

OPERATION

• IDENTIFICATION OF HIGH RISK PATIENT

 CHARACTERISTICS OF HIGH RISK
INTRAABDOMINAL INFECTIONS PATIENTS

Pre-existing chronic conditions Patient specific factors

oLiver disease Advance age(>70 y)
oRenal disease Immunosuppression
Disease specific factors oPoor nutritional status

oHigh APACHE ll score (>15) oCorticosteroid therapy

oHealth care associated infection
oDelay in initial intervention(>24 h) oOrgan transplant
oInability to obtain source control
Malignancy
 EXAMINATION
What organ is involved?

How bad the patient is?

Localized
Peritoniti
s
Diffuse
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME CRITERIA
(S.I.R.S)

FINDINGS VALUE

TEMPERATURE <36c or>38c

HEART RATE >90/min

RESPIRATORY RATE >20/min or paCO2<32 mmHg

WBC <4x10⁹/L , >12x10⁹/L or 10% bands

any two of them present

 SEPSIS

S.I.R.S + INFECTION
 SEVERE SEPSIS

Organ failure
+
Hypotension
 SEPTIC SHOCK

Severe sepsis
+
Hypo perfusion
+
Organ failure
+
Refractory to fluid resuscitation
 INVESTIGATIONS
• Hematology
• Urea /creatinine
• PT,APTT,INR
• Blood Glucose level*
• ABGs
• Serum lactate level*
• Serum Amylase/lipase
• Urine D/R
• CRP
• Sonology
• CT scan
 RESUSCITATION
FLUIDS
Type of Fluid& amount of fluid?
• Crystalloid v/s colloid
• Albumin

When to use VASOPRESSOR?

• Nor-adrenaline
• Dopamine
• Phenylephrine
• Dobutamine
 ANTIBIOTIC Timings
Appropriate and timely empiric antibiotic
coverage is imperative

Inappropriate coverage increase hospital

stay, postoperative abcesses,and mortality
that can’t be reversed if subsequent
appropriate antibiotics are added later in
clinical course
Surgical Clinics of North America
December 2014
In severe sepsis, appropriate coverage should
be started within 1 hour as recommended by
SSC

Surgical Clinics of North America

Dec 2014
 Timing of Initiation of Antimicrobial Therapy
• Diagnosed OR Likely case of intra
IMMEDIATE abdominal sepsis-septic shock

WITHIN AN
• Without septic shock
HOUR

BOOSTER
• At time of source control
DOSE

IDSA GUIDELINE
 MICROBIOLOGICAL EVALUATION

BLOOD C/S

INDICATIONS:

Clinically toxic
Immuno compromised

IDSA GUIDELINES
 MICROBIOLOGICAL EVALUATION

• Pus for C/S

 Agents and Regimens for the Initial Empiric Treatment of Extra-
biliary Complicated Intra-abdominal Infection
Regimen Community acquired
infection
Mild-to-moderate severity: perforated or abscessed
perforated or abscessed appendicitis and other
appendicitis and infections of mild-to-moderate
other infections of mild-to- severity
moderate severity High risk or severity: severe
physiologic disturbance,
advanced age, or
immunocompromised state

Cefoxitin, ertapenem, Imipenem-cilastatin,

SINGLE AGENT moxifloxacin, tigecycline, and meropenem, doripenem, and
ticarcillin-clavulanic acid piperacillin-tazobactam
Cefepime, ceftazidime,
COMBINATION ciprofloxacin, or levofloxacin,
Cefazolin, cefuroxime, each in combination with
ceftriaxone, cefotaxime, metronidazolea
ciprofloxacin, or levofloxacin,
each in combination with
metronidazole
IDSA GUIDELINES -2009
High-Risk Community-Acquired Infection in
Adults

Quinolone-resistant E. coli have become common in

some communities, and quinolones should not be
used unless hospital surveys indicate >90%
susceptibility of E. coli to quinolones

IDSA GUIDELINE-2009
 RECOMMENDED ANTIMICROBIAL
REGIMENS
Mild-to-moderate severity: High risk or severity: severe
REGIMEN perforated or abscessed appendicitis physiologic disturbance,
and other infections of mild-to- advanced age, or
moderate severity immunocompromised state

Cefoxitin, ertapenem, moxifloxacin, Imipenem-cilastatin,

SINGLE AGENT tigecycline, and ticarcillin-clavulanic meropenem, doripenem,
acid and piperacillin-tazobactam

Cefazolin, cefuroxime, ceftriaxone, Cefepime, ceftazidime,

COMBINATION cefotaxime, ciprofloxacin, or ciprofloxacin, or
levofloxacin, each in combination levofloxacin, each in
with metronidazolea combination with
metronidazolea
 Empiric antibiotics recommendation
for high risk IAI patients
Local organism carbapenems Piperacillin- Ceftazidime or
Tazobactam cefipime
(+Metronidazole)

20% resistant recommended recommended recommended

p.aeruginosa
ESBL-producing
enterobacter sp
Acinobacter
MDR
GNR

ESBL-Producing recommended recommended

Enterobacter sp
>20% of recommended recommended
p.aeruginosa
resistant to
ceftazidime

MRSA
 Empiric antibiotics recommendation
for high risk IAI patients
Local organism Aminoglycosides Vancomycin

20% resistant p.aeruginosa

ESBL-producing enterobacter
sp
Acinobacter
MDR
GNR

ESBL-Producing Enterobacter recommended

sp
>20% of p.aeruginosa recommended
resistant to ceftazidime

MRSA recommended
 Antifungal Therapy
• If Candida is grown from intra-abdominal
cultures
• Fluconazole  choice for treatment
Candida albicans

• Fluconazole-resistant Candida species 

echinocandin (caspofungin, micafungin, or
anidulafungin)

IDSA GUIDELINE-2009
 Anti-MRSA Therapy

• Vancomycin suspected or proven intra-

abdominal infection due to MRSA
• Linezolid

IDSA GUIDELINE-2009
APPROPRIATE DURATION OF THERAPY

Limited to 4–7 days, unless it is difficult to

achieve adequate source control

IDSA GUIDELINE-2009
 WHEN TO STOP ANTIBIOTICS?
Clinician should recognize
• Bacterial and fungal source are likely,
• Blood cultures may be negative if empiric
therapy is administered.

• Decision to continue , de escalate, or stop

antimicrobial is made on clinician judgment
with available information
 Suspected Treatment Failure
• Patients with persistent or recurrent clinical
evidence of intra-abdominal infection after
4–7 days of therapy, appropriate diagnostic
investigation should be undertaken.
• CT or ultrasound imaging.
• Antimicrobial therapy effective against the
organisms initially identified should be
continued
 ANTIBIOTICS STEWARDSHIP
Ensure:
• Appropriate combination
• Length of therapy

• Prevents resistance
• Reduce toxicity
• Reduce costs

CLINICS OF NORTH AMERICA APRIL2015

 SOURCE CONTROL
• Should always be aggressively sought and
addressed within 6 hours

• If not done result in resuscitation failure

• A damage control approach is appropriate

for septic shock
Clinical Indications for Damage Control

• Hemodynamic instability
• On-going contamination or need for further
debridement
• Tissue/organ ischemia
• Loss of abdominal domain
• Development of/risk for abdominal
compartment syndrome

Surgical clinics of North America

December 2014
WHAT ARE THE PROPER PROCEDURES FOR
OBTAINING ADEQUATE SOURCE CONTROL?
An appropriate source control

1. Procedure to drain infected foci.

2. Control ongoing peritoneal contamination by diversion or

resection.

3. Restore anatomic and physiological function to the feasible

extent.

4. No anastomosis in high risk patient.

IDSA GUIDELINES-2009
Source control should be done within 6 hours.*

Sonological Percutaneous drainage of localized

abscesses *
PLANNED/ON DEMAND RE-LAPARATOMY

In severe peritonitis
Mandatory or scheduled re-laparotomy is
NOT recommended in the ABSENCE of
intestinal discontinuity, abdominal fascial
loss that prevents abdominal wall closure, or
intra-abdominal hypertension
INTENSIVE CARE UNIT MANAGEMENT

• Intubation and ventilator

• Organ support/monitoring

• Fluid/antibiotics/O2therapy/output

• Vital monitoring /inotropic support/steroids

• Immediately available indicators of global tissue
perfusion include arterial PH and LACTIC ACID

• These indicators of metabolic state are important &

mortality is as high as 46.1% in patient with both
hypotension and lactate greater than 4

• Once the resuscitation has restored adequate oxygen

delivery, lactate should be metabolized and PH
should return to normal
• Persistent acidosis indicates inadequate source
control.

• Lactic acid can be use as a marker of hypoperfusion

and depth of the shock state
 NUTRITION
• Nutrition management in critically ill patients is an
important and frequently overlooked aspect of
care.

• It is perferable that patients be fed enterally,which

can be accomplished orally or via gastric or enteral
feeding tube IF permissable
• If enteral feeding is not possible total parenteral
nutrition can be instituted per hospital protocols.

• No direct evidence defines benefit or harm of

parenteral nutrition in the first 48 hours in sepsis

• An adjunct to nutritional regimens is stress- ulcer

prophylaxis
• H2-blocker or proton pump inhibitor

• DVT prophylaxis

Surgical Clinics of North America APRIL2015

 RESPONSE TO TREATMENT

INDICATIONS
AFTER 48
REWASHOUT HOURS
RATIONALE
 ORIGINAL STUDY

WARD 2
JINNAH POSTGRADUATE MEDICAL CENTRE
KARACHI
TOTAL NUMBER OF PATIENTS IN 15
MONTHS IN WARD2 JPMC

Total number of patients 95

 SEX OF PATIENT
70

60

50

40

30

20

10

0
male female
 AGE OF PATIENTS
50
45
40
35
30
25
20
15
10
5
0
60-70( years) 40-70(years) 20-40(years)
 ETIOLOGY
50
45
40
35
30
25
20
15
10
5
0
p ) cy x n
Ty n di io io
n
/ a n at at
(T
B i gn p e
rfo
r r
al Ap rfo
ti on M p e
pe
ed l
ora rat na ac
h
rf fo de
lp
e er uo om
a P D St
Ile
DEGREE OF INTRA-ABDOMINAL INFECTION
40

35

30

25

20

15

10

0
S.I.R.S SEPSIS SEVERE SEPSIS SEPTICSHOCK
Suspected pathogens in intra-abdominal
infection
Column1
3% 2% 1%
7%
E.COLI
ENTEROBACTER 85%
34%
Klebsilla
pseudomonas
24% ACINOBACTER
MRSA
CANDIDA

29%
 ANTIBIOTICS SENSITIVITY
5%
10%
23%

Amikacin
meropenem
imipenem
17% cefaprazone-sulbactem
Augmentin
polymyxin-B 20%
Colistin
22%

22%
 OUTCOME
36
35
34
33
32
31
30
29
28
27
Mortality Complications Discharge
 CONCLUSION
• Management of intra abdominal infection is a
surgical challenge.

• Focus history , proper examination , investigation

has major role in management

• Resuscitation ,proper antibiotics, adequate source

control, bundle care of safety are important tools
of management of intra abdominal infection.