Definition

IDSA and Surgical Infection Society define complicated intra-abdominal infection as infection extending beyond the hollow viscus of origin into the peritoneal space that is associated with abscess formation or peritonitis.

Risk factors for source control failure

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  Delay in treatment (>24 h)

  
  
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  High severity of illness (Acute Physiology and Chronic Health Evaluation II score ≥15)

  
  
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  Age >70 years

  
  
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  Medical comorbidity

  
  
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  Degree of organ dysfunction

  
  
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  Low albumin

  
  
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  Poor nutritional status

  
  
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  Degree of peritoneal involvement or diffuse peritonitis

  
  
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  Inability to achieve adequate debridement or drainage

  
  
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  Malignancy

Pathogens in order of prevalence

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  Escherichia coli

  
  
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  Bacteroides species

  
  
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  Streptococcus species

  
  
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  Clostridium species

  
  
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  Peptostreptococcus species, Eubacterium species

  
  
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  Klebsiella species, Pseudomonas aeruginosa

  
  
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  Prevotella species, Enterococcus faecalis

Treatment

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  Antibiotic regimen ( Table 10.1 )

  
  
  
  

  Table 10.1

  
  

  Empiric Antibiotic Therapy for Complicated Intra-Abdominal Infection

  
  

  Adapted from 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(12): 133–164.

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  TYPE OF INFECTION	ANTIBIOTIC REGIMEN
  Community-Acquired Extra-Biliary Intra-Abdominal Infection
  Mild-moderate severity	Cefoxitin Ertapenem Moxifloxacin Tigecycline Ticarcillin-clavulanic acid (unavailable in U.S.) Cefazolin + metronidazole Cefuroxime + metronidazole Ceftriaxone + metronidazole Cefotaxime + metronidazole Ciprofloxacin a + metronidazole Levofloxacin a + metronidazole
  High severity	Imipenem-cilastatin Meropenem Doripenem Piperacillin-tazobactam Cefepime + metronidazole Ceftazidime + metronidazole Ciprofloxacin a + metronidazole Levofloxacin a + metronidazole
  Biliary Intra-Abdominal Infection
  Community-acquired acute cholecystitis of mild to moderate severity	Cefazolin Cefuroxime Ceftriaxone
  Community-acquired acute cholecystitis of high severity or acute cholangitis following bilio-enteric anastomosis	Imipenem-cilastatin Meropenem Doripenem Piperacillin-tazobactam Cefepime + metronidazole Ciprofloxacin a + metronidazole Levofloxacin a + metronidazole
  Health care–associated biliary infection	Vancomycin plus one of the following: • Imipenem-cilastatin • Meropenem • Doripenem
  	• Piperacillin-tazobactam • Cefepime + metronidazole • Ciprofloxacin a + metronidazole • Levofloxacin a + metronidazole
  Health Care–Associated Intra-Abdominal Infection
  <20% resistant Pseudomonas aeruginosa , ESBL-producing Enterobacteriaceae , Acinetobacter , or other MDR GNB	Imipenem-cilastatin Meropenem Doripenem Piperacillin-tazobactam Cefepime + metronidazole Ceftazidime + metronidazole
  ESBL-producing Enterobacteriaceae , Pseudomonas aeruginosa >20% resistant to ceftazidime	Imipenem-cilastatin Meropenem Doripenem Piperacillin-tazobactam Aminoglycoside
  MRSA	Vancomycin

   
  

  ESBL , Extended-spectrum β-lactamase; GNB , Gram-negative bacilli; MDR , Multidrug resistant; MRSA , Methicillin-resistant Staphylococcus aureus

  
  

  a Recommend reviewing local population susceptibility reports given increasing resistance of Escherichia coli to fluoroquinolones

  
  
  
  
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  Antibiotic dosing ( Table 10.2 )

  
  
  
  

  Table 10.2

  
  

  Antibiotic Dosing for Complicated Intra-Abdominal Infection

  
  

  Data from 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(12):133–164.

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  ANTIBIOTIC	STANDARD DOSE (IV)	RENAL DOSING	COMMENTS
  Β-Lactam/β-Lactamase Inhibitor Combination
  Piperacillin-tazobactam	Non-PSA: 3.375 g q6h PSA: 4.5 g q6h	Non-PSA: CrCl 20–40: 2.25 g q6h CrCl <20: 2.25 g q8h HD: 2.25 g q12h a PSA: CrCl 20–40: 3.375 g q6h CrCl <20: 2.25 g q6h HD: 2.25 g q8h a	Off-label extended infusion: 3.375–4.5 g ×1 over 30 min, followed 4 h later by 4 h infusion q8h
  Carbapenems (Cross-Sensitivity With PCN Allergy)
  Doripenem	500 mg q8h	CrCl 30–50: 250 mg q8h CrCl 11–29: 250 mg q12h HD: 250 mg q24h a ; If PSA, 500 mg q12h ×1 then 500 mg 24 h a	Similar spectrum of activity as meropenem except more potent in vitro activity against PSA than meropenem
  Ertapenem	1 g q24h	CrCl ≤30 and HD: 500 mg daily	Compared to imipenem or meropenem, less active against PSA, Acinetobacter , enterococci , and PCN-resistant pneumococci
  Imipenem-cilastatin	500 mg q6h or 1 g q8h	CrCl 60–89: 500 mg q6h CrCl 30–59: 500 mg q8h CrCl 15–29 and HD: 500 mg q12h a CrCl <15 without HD: avoid use	Consider decreasing dose in patients <70 kg to prevent seizures
  Meropenem	1 g q8h	CrCl 26–50: same dose q12h CrCl 10–25: half dose q12h CrCl <10: half dose q24h HD: 500 mg q24h a	Similar spectrum of activity as imipenem; slightly lower risk of seizures than imipenem
  Cephalosporins (10% Cross-Sensitivity With PCN Allergy)
  Cefazolin	1–2 g q8h	CrCl 11–34: 50% dose q12h CrCl ≤10 and HD: 50% dose q24h a	—
  Cefepime	2 g q8–12h	CrCl 30–60: 2 g q12–24h CrCl <30: 1–2 g q24h HD: 0.5–1 g q24h a	Risk of seizures in renal insufficiency
  Cefotaxime	2 g q8h	CrCl <20: 50% dose q8h HD: 1–2 g q24h a	—
  Cefoxitin	2 g q6h	CrCl 30–50: 2 g q8–12h CrCl 10–29: 2 g q12–24h CrCl 5–9: 2 g ×1 then 1 g q12–24h CrCl <5 and HD: 2 g ×1 then 1 g q24–48h a	—
  Ceftazidime	2 g q8h	CrCl 31–50: 2 g q12h CrCl 16–30: 2 g q24h CrCl ≤15 and HD: 1 g q24h a	Possible cross-sensitivity between aztreonam and ceftazidime (<5%); avoid aztreonam if history of life-threatening reaction or anaphylaxis to ceftazidime. Other cephalosporins do not have the same risk as ceftazidime
  Ceftriaxone	2 g q24h	—	—
  Cefuroxime (Zinacef)	1.5 g q8h	CrCl 10–20: 1.5 g q12h CrCl <10 and HD: 1.5 g q24h a	—
  Ceftazidime 2 g-avibactam 0.5 g (Avycaz 2.5 g)	2.5 g q8h	CrCl 31–50: 1.25 g q8h CrCl 16–30: 0.94 g q12h CrCl 6–15: 0.94 g q24h CrCl ≤5 and HD: 0.94 g q48h a	Reserve for MDR PSA, and ESBL- and KPC-producing Enterobacteriaceae. Combine with metronidazole
  Ceftolozane 1 g-tazobactam 0.5 g (Zerbaxa 1.5 g)	1.5 g q8h	CrCl 30–50: 750 mg q8h CrCl 15–29: 375 mg q8h CrCl <15: not studied HD: 750 mg ×1 then 150 mg q8h a	Reserve for MDR PSA and ESBL-producing Enterobacteriaceae. Combine with metronidazole
  Glycylcycline
  Tigecycline	100 mg ×1 then 50 mg q12h	—	Increase in all-cause mortality observed in meta-analysis of Phase 3 and 4 clinical trials where greatest differences seen with ventilator-associated pneumonia
  Fluoroquinolones
  Ciprofloxacin	400 mg q12h	CrCl 5–29 and HD: 400 mg q24h a	ADR: tendonitis/tendon rupture, CNS effects, peripheral neuropathy, hepatotoxicity, crystalluria, photosensitivity, QT prolongation. CI: myasthenia gravis, children due to musculoskeletal toxicity
  Levofloxacin	750 mg q24h	CrCl 20–49: 750 mg q48h CrCl 10–19: 750 mg ×1, then 500 mg q48h HD: 750 mg ×1, then 500 mg q48h a	“
  Moxifloxacin	400 mg q24h	—	“
  Nitroimidazole
  Metronidazole	500 mg q8h	Give post HD on HD days	—
  Aminoglycosides
  Gentamicin or tobramycin	5–7 mg/kg q24h b	CrCl 20–60: 5–7 mg/kg q36–48 h b CrCl <20 and HD: 1–2.5 mg/kg LD, then based on level a , c	Consult pharmacist for dosing. Goal for once daily dosing: refer to Hartford nomogram d . Use adjusted BW for obese
  Amikacin	15–20 mg/kg q24h b	CrCl 20–60: 15–20 mg/kg q36–48h b CrCl <20 and HD: 5 mg/kg LD then based on level a , c	“
  Monobactam
  Aztreonam	1–2 g q6–8h	CrCl 10–30: 0.5–1 g q6–8h CrCl <10: 250–500 mg q6–8h HD: 1–2 g LD, then 250–500 mg q6–8h a	Possible cross-sensitivity between aztreonam and ceftazidime (<5%); see comment on ceftazidime
  Glycopeptide
  Vancomycin	15–20 mg/kg q8–12h	CrCl 15–50: 750–1500 mg q24h Max: 2 g/dose CrCl <15: 750–1500 mg based on level HD: 500–1000 mg based on level a	Consult pharmacist for dosing Goal trough: 10–15 mcg/mL (15–20 mcg/mL if visceral abscesses) Use actual BW for obese
  Notes: • Surgical management is critical in most intra-abdominal infections • 4–5 days is the recommended duration who have adequate source control; longer duration is appropriate if inadequate or uncertain source control
  • Empiric antifungal may be considered for upper gastrointestinal perforations, recurrent bowel perforations, surgically treated pancreatitis, heavy colonization with Candida species, or presence of yeast on intra-abdominal cultures • Candida albicans : Fluconazole IV 800 mg ×1 then 400 mg daily • Fluconazole-resistant Candida species: • Anidulafungin IV 200 mg ×1 then 100 mg daily • Caspofungin IV 70 mg ×1 then 50 mg daily • Micafungin IV 100 mg daily • Antienterococcal therapy: consider in postoperative infection, those who have previously received cephalosporins or other antimicrobial agents selecting for Enterococcus species, immunocompromised patients, and those with valvular heart disease or prosthetic intravascular materials • Anti-MRSA therapy: consider in patients with MRSA or MDRO risk factors (advanced age, comorbid medical conditions, previous hospitalization/surgery, recent antibiotic agents)

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