intra abdominal 2009

7/25/2019 Intra Abdominal 2009

1/8

IntraIntra--abdominalabdominal

InfectionsInfections

Marnie Peterson, Pharm.D., Ph.D., BCPSMarnie Peterson, Pharm.D., Ph.D., BCPS

College of PharmacyCollege of Pharmacy

[email protected]@umn.edu

2006 Marnie Peterson. This presentation is provided to facilitate the learning of participants within

this course. It may not be modified, reproduced and/or circulated for other means without the

permission of the author.

ObjectivesObjectives

Describe pathogenesis & clinical characteristicsDescribe pathogenesis & clinical characteristics

of intraof intra--abdominal infectionsabdominal infections Identify most likely etiologicIdentify most likely etiologic organism(sorganism(s))

Review appropriate drug therapyReview appropriate drug therapy

IntraIntra--abdominal Infectionsabdominal InfectionsInfections contained within the peritoneum orInfections contained within the peritoneum or

retroperitoneal spaceretroperitoneal space..

Peritoneal cavity contains:Peritoneal cavity contains: StomachStomach

Jejunum, IleumJejunum, Ileum

AppendixAppendix

Large intestine (colon)Large intestine (colon)

Liver, gallbladder and spleenLiver, gallbladder and spleen

Retroperitoneal space:Retroperitoneal space: DuodenumDuodenum

PancreasPancreas

KidneysKidneys

IntraIntra--abdominal Infectionsabdominal Infections

AppendicitisAppendicitis

PeritonitisPeritonitis

IntraIntra--abdominal Abscessabdominal Abscess

DiverticulitisDiverticulitis

AntibioticAntibiotic--Associated DiarrheaAssociated Diarrhea ((Clostridium difficileClostridium difficile))

Food Poisoning/TravelerFood Poisoning/Travelers Diarrheas Diarrhea

Helicobacter pyloriHelicobacter pylori

Pelvic Inflammatory DiseasePelvic Inflammatory Disease

ViralViral

ParasiticParasitic

Anatomy of the GI TractAnatomy of the GI Tract GI microfloraGI microflora

depends on thedepends on the

anatomic site!anatomic site! Stomach:H. pylori

LactobacilliUpperIntestine:StreptococciEnterococciStaphylococciE. coli

Klebsiella

Bacteroides

Ileum:

StreptococciStreptococci

StaphylococciStaphylococci

Escherichia coliEscherichia coli

KlebsiellaKlebsiella

EnterobacterEnterobacter

Bacteroides

Clostridium

Colon:

BacteroidesBacteroides

PeptostreptococciPeptostreptococci

ClostridiumClostridium

BifidobacteriumBifidobacterium

Escherichia coliEscherichia coli



EnterococciEnterococci


Normal GI MicrofloraNormal GI Microflora Stomach:Stomach:

Total bacterial count 0Total bacterial count 0--101088 log organisms/glog organisms/gHelicobacter pyloriHelicobacter pylori

StreptococciStreptococci

LactobacilliLactobacilli

Upper Small Intestine:Upper Small Intestine: Total bacterial count 0Total bacterial count 0--101055 log organisms/glog organisms/g

AerobesAerobes



LactobacilliLactobacilli

E. coli, KlebsiellaE. coli, Klebsiella

AnaerobesAnaerobesBacteroidesBacteroides


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Normal GI MicrofloraNormal GI Microflora IleumIleum

Total bacterial count 10Total bacterial count 1033--101099 log organisms/glog organisms/g

Aerobes:Aerobes: StreptococciStreptococci


Escherichia coli, KlebsiellaEscherichia coli, Klebsiella EnterobacterEnterobacter

Anaerobes:Anaerobes: BacteroidesBacteroides


Large Intestine (Colon)Large Intestine (Colon) Total bacterial count 10Total bacterial count 101010--10101212 log organisms/glog organisms/g

Anaerobes:Anaerobes: BacteroidesBacteroides

PeptostreptococciPeptostreptococci


BifidobacteriaBifidobacteria

Aerobes:Aerobes: Escherichia coli, KlebsiellaEscherichia coli, Klebsiella





Inflammation of theInflammation of the

serous lining of theserous lining of theperitoneal cavity dueperitoneal cavity due

to:to:

MicroorganismsMicroorganisms

ChemicalsChemicals

IrradiationIrradiation

Foreign body injuryForeign body injury


PrimaryPrimary

No focus of disease is evidentNo focus of disease is evident

Bacteria transported from blood stream toBacteria transported from blood stream toperitoneal cavity (Cirrhosis, CAPD)peritoneal cavity (Cirrhosis, CAPD)

SecondarySecondary

Acute perforation of the GI tract (gastric,Acute perforation of the GI tract (gastric,diverticulardiverticular (diverticulitis), appendix (appendicitis),(diverticulitis), appendix (appendicitis),gallbladder, tumor perforations) [66%]gallbladder, tumor perforations) [66%]

PostPost--operative peritonitis [24%]operative peritonitis [24%]

PostPost--traumatic peritonitis [10%]traumatic peritonitis [10%]

Seiler CA, et al. Surgery. 2000; 127:178-184.


Pip/Pip/tazotazo, amp/, amp/sulbsulb,,

carbapenemcarbapenem,, tigecyclinetigecycline,,

moxifloxacinmoxifloxacin,,

(amp+(amp+ cipro/levo/AGcipro/levo/AG ++metronidazolemetronidazole))

CefotaximeCefotaxime,,

pip/pip/tazotazo, amp/, amp/sulbsulb,,

ceftriaxoneceftriaxone,,

carbapenemcarbapenem, FQ,, FQ,vancovanco (MRSA)(MRSA)

TreatmentTreatment

EnterobacteriaceaeEnterobacteriaceae

BacteroidesBacteroides


P.P. aeruginosaaeruginosa

EnterobacteriaceaeEnterobacteriaceae (63%)(63%)

S.S.pneumoniaepneumoniae(15%)(15%)

EnterococciEnterococci (6(6--10%)10%)

anaerobes (


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Primary PeritonitisPrimary Peritonitis

Relatively infrequentRelatively infrequent

25% of patients with alcoholic cirrhosis25% of patients with alcoholic cirrhosis 60% of all patients on chronic ambulatory60% of all patients on chronic ambulatory

peritoneal dialysis (CAPD) will have at least oneperitoneal dialysis (CAPD) will have at least oneepisode in 1episode in 1stst year.year.

Average incidence in CAPD patients is 1.3 to 1.4Average incidence in CAPD patients is 1.3 to 1.4episodes/yr.episodes/yr.

Catheter connecting abdominal cavity to exteriorCatheter connecting abdominal cavity to exteriorbody is a major risk factor.body is a major risk factor.

?????Clinical Question??????????Clinical Question?????

Recommend dosing forRecommend dosing forintraperitoneal administration of anintraperitoneal administration of an

antibiotic for a CAPD patient withantibiotic for a CAPD patient with

a Staphylococcus peritonitisa Staphylococcus peritonitis

Peritonitis in CAPDPeritonitis in CAPD Antibiotics may be given intraperitoneal via theAntibiotics may be given intraperitoneal via the

dialysate: (exchanges every 4 to 6 hrs)dialysate: (exchanges every 4 to 6 hrs) Gentamicin and tobramycin: 8mg/LGentamicin and tobramycin: 8mg/L

Clindamycin: 1 to 3 mg/LClindamycin: 1 to 3 mg/L Penicillin G: 50,000 units/LPenicillin G: 50,000 units/L

Cephalosporins: 125 mg/LCephalosporins: 125 mg/L

Ampicillin: 50 mg/LAmpicillin: 50 mg/L Vancomycin: 30 mg/LVancomycin: 30 mg/L AmphotericinAmphotericin B: 3 mg/LB: 3 mg/L

Reasonable empiric therapyReasonable empiric therapy GentamicinGentamicin oror tobramycintobramycin PLUSPLUSvancomycinvancomycin CeftazidimeCeftazidime PLUSPLUSvancomycinvancomycin

Duration: 2 to 3 weeksDuration: 2 to 3 weeks

Appendicitis CaseAppendicitis Case

LF, an 18 yr female, was admitted to the hospital withLF, an 18 yr female, was admitted to the hospital with

diffuse abdominal pain, diarrhea, and nausea. Her paindiffuse abdominal pain, diarrhea, and nausea. Her pain

was localized to the right side of the abdomen.was localized to the right side of the abdomen.

CefazolinCefazolinwas initiated and LF was taken to surgery forwas initiated and LF was taken to surgery for

a ruptured appendix to be removed.a ruptured appendix to be removed.

What are the considerations in a ruptured appendix?What are the considerations in a ruptured appendix?

MicrobialMicrobial

TherapeuticsTherapeutics

Appendicitis Case, cont.Appendicitis Case, cont. LF, an 18 yr female, was admitted to the hospital withLF, an 18 yr female, was admitted to the hospital with

diffuse abdominal pain, diarrhea, and nausea. Her paindiffuse abdominal pain, diarrhea, and nausea. Her painwas localized to the right side of the abdomen.was localized to the right side of the abdomen.

CefazolinCefazolinwas initiated and LF was taken to surgery forwas initiated and LF was taken to surgery fora ruptured appendix to be removed.a ruptured appendix to be removed.

What are the considerations in a ruptured appendix?What are the considerations in a ruptured appendix? MicrobialMicrobial

Staphylococcus? NOT most importantStaphylococcus? NOT most important

E. coli? YesE. coli? Yes

Anaerobes? YesAnaerobes? Yes

TherapeuticsTherapeutics CefazolinCefazolin alone? Noalone? No

UnasynUnasyn yesyes --why?why?


Highest incidence 10Highest incidence 10--19y/o,19y/o,male>femalemale>female

PathophysiologyPathophysiology:: Relationship to onset ofRelationship to onset of sxsx

00--24h after24h after sxsx onset:onset: obstruction within appendixobstruction within appendix

inflammation & occlusion of vascular & lymphatic flowinflammation & occlusion of vascular & lymphatic flowbacterial overgrowthbacterial overgrowth necrosisnecrosis

>48h after>48h after sxsx onset:onset: perforation (60%)perforation (60%)abscess/peritonitisabscess/peritonitis

EarlyEarly sxsx:: dull, nondull, non--localized RLQ pain, indigestion,localized RLQ pain, indigestion,bowel irregularity, flatulencebowel irregularity, flatulence

LaterLater sxsx:: pain/tenderness more localized, N/Vpain/tenderness more localized, N/V Fever >103F, leukocytes >15000: perforation likelyFever >103F, leukocytes >15000: perforation likely


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Acute, nonAcute, non--perforated appendicitisperforated appendicitis

cefazolincefazolin ++ metronidazolemetronidazole

Perforated appendicitisPerforated appendicitis Cover enteric gramCover enteric gramrods and anaerobesrods and anaerobes

(2(2ndnd/3/3rdrd generationgeneration cephceph or FQ) +or FQ) + metronidazolemetronidazole

CefoxitinCefoxitin,, piperacillin/tazobactampiperacillin/tazobactam,, ampicillin/sulbactamampicillin/sulbactam,,

imipenemimipenem

Antibiotics are started before surgery, continued for 7Antibiotics are started before surgery, continued for 7--

10 days10 days

Switch to PO based on patient statusSwitch to PO based on patient status

For initial treatment in a pt with a ruptured appendixFor initial treatment in a pt with a ruptured appendixand no other contributing factors, which of theand no other contributing factors, which of thefollowing is an incorrect choice?following is an incorrect choice? Ampicillin/sulbactam (Unasyn) +/Ampicillin/sulbactam (Unasyn) +/--AminoglycosideAminoglycoside

Piperacillin/tazobactam (Zosyn) +/Piperacillin/tazobactam (Zosyn) +/--AminoglycosideAminoglycoside

TigecyclineTigecycline ((TigecilTigecil) +/) +/--AminoglycosideAminoglycoside

Clindamycin + Ampicillin +Clindamycin + Ampicillin +AminoglycosideAminoglycoside

ClindamycinClindamycin ++ MetronidazoleMetronidazole

MoxifloxacinMoxifloxacin + Metronidazole+ Metronidazole

Sample Exam Question:Sample Exam Question:

Sample Exam Question:Sample Exam Question: For initial treatment in a pt with a ruptured appendixFor initial treatment in a pt with a ruptured appendix

and no other contributing factors, which of theand no other contributing factors, which of thefollowing is an incorrect choice?following is an incorrect choice? Ampicillin/sulbactam (Unasyn) +/Ampicillin/sulbactam (Unasyn) +/--AminoglycosideAminoglycoside

Piperacillin/tazobactam (Zosyn) +/Piperacillin/tazobactam (Zosyn) +/--AminoglycosideAminoglycoside

TigecyclineTigecycline ((TigecilTigecil) +/) +/--AminoglycosideAminoglycoside

Clindamycin + Ampicillin +Clindamycin + Ampicillin +AminoglycosideAminoglycoside

ClindamycinClindamycin ++ MetronidazoleMetronidazole

MoxifloxacinMoxifloxacin + Metronidazole+ Metronidazole

Appendicitis Case, cont.Appendicitis Case, cont. LF improved postLF improved post--operatively & completed 7d course of POoperatively & completed 7d course of PO

cephalexincephalexin. 4d after completing antibiotics she felt diffuse pain. 4d after completing antibiotics she felt diffuse painover the appendectomy site. Abdominal CT scan revealed aover the appendectomy site. Abdominal CT scan revealed aperitoneal abscess. Abscess was drained & fluid sent to the lab.peritoneal abscess. Abscess was drained & fluid sent to the lab.

WhatWhat organism(sorganism(s) are most likely to be responsible for the) are most likely to be responsible for theabscess?abscess? Likely MRSA, not covered byLikely MRSA, not covered by cephalexincephalexin

Gram negative bacteria not covered by 1Gram negative bacteria not covered by 1stst generationgeneration cephalosporinscephalosporins

Anaerobic bacteria not covered byAnaerobic bacteria not covered by cephalexincephalexin

Was theWas the cephalexincephalexin an appropriate choice ofan appropriate choice of abxabx for LF?for LF? No, LF should have remained in the hospital for 7No, LF should have remained in the hospital for 7 --10 days with IV10 days with IV txtx

No, there was not appropriate coverage with a 1No, there was not appropriate coverage with a 1 stst generationgeneration cephceph

Yes, butYes, but metronidazolemetronidazole should have been added for anaerobic coverageshould have been added for anaerobic coverage

Appendicitis Case, cont.Appendicitis Case, cont. WhatWhat organism(sorganism(s) are most likely to be responsible for the) are most likely to be responsible for the

abscess?abscess? Likely MRSA, not covered byLikely MRSA, not covered by cephalexincephalexin: MRSA not most likely here: MRSA not most likely here

*Gram negative bacteria not covered by 1st generation*Gram negative bacteria not covered by 1st generation cephalosporinscephalosporins::GramGrams likely involved ands likely involved and cephalexincephalexin has limited gramhas limited gramcoveragecoverage

*Anaerobic bacteria not covered by*Anaerobic bacteria not covered by cephalexincephalexin: anaerobes likely involved,: anaerobes likely involved,cephalexincephalexin not good choice for anaerobesnot good choice for anaerobes

Was theWas the cephalexincephalexin an appropriate choice ofan appropriate choice of abxabx for LF?for LF? No, LF should have remained in the hospital for 7No, LF should have remained in the hospital for 7 --10 days with IV10 days with IV txtx: no,: no,

outpatientoutpatient txtx is okay with appropriateis okay with appropriate abxabx choicechoice

*No, there was not appropriate coverage with a 1st generation*No, there was not appropriate coverage with a 1st generation cephceph: not: notadequate coverage of gramadequate coverage of grams and anaerobess and anaerobes

Yes, butYes, but metronidazolemetronidazole should have been added for anaerobic coverage:should have been added for anaerobic coverage:an agent with anaerobe coverage should be added, but also need gan agent with anaerobe coverage should be added, but also need gramram --coveragecoverage



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IntraIntra--abdominal Abscessabdominal Abscess Abscess:Abscess: purulent collection of fluid, necrotic debris,purulent collection of fluid, necrotic debris,

bacteria, inflammatory cells that is walledbacteria, inflammatory cells that is walled

off/encapsulated by adjacent healthy cells in an attemptoff/encapsulated by adjacent healthy cells in an attemptto keep pus from infecting neighboring structures.to keep pus from infecting neighboring structures.

encapsulation can prevent immune cells/encapsulation can prevent immune cells/abxabx from attackingfrom attacking

contained bacteria, low O2 incontained bacteria, low O2 in capsulecapsuleanaerobesanaerobes thrivethrive

here!here!

Result of chronic inflammation, develop over daysResult of chronic inflammation, develop over days--yrsyrs

Located within peritoneal cavity or visceral organsLocated within peritoneal cavity or visceral organs

May range from a few milliliters to a liter in volumeMay range from a few milliliters to a liter in volume

Ruptured abscessRuptured abscess

spread ofspread of bacteria+toxinsbacteria+toxins intointo peritoneumperitoneumperitonitisperitonitis

Spread ofSpread of bacteria+toxinsbacteria+toxins into systemicinto systemic circulationcirculationsepsissepsis,,multimulti--organ failure, deathorgan failure, death

Presentation:Presentation: nonspecific low grade or spiking fever,nonspecific low grade or spiking fever,

abdominal pain/discomfort +/abdominal pain/discomfort +/-- distensiondistension

Labs:Labs: leukocytosisleukocytosis , +/, +/-- positive blood cultures, +/positive blood cultures, +/--

hyperglycemiahyperglycemia

Ultrasound, GI contrast study, or CT scan may be usedUltrasound, GI contrast study, or CT scan may be used

for evaluationfor evaluation



MicrobiologyMicrobiology

usually mixed infection: aerobes & anaerobes withinusually mixed infection: aerobes & anaerobes within

the same abscessthe same abscess

E. coliE. coli



B. fragilisB. fragilis


Management ofManagement of

IntraIntra--Abdominal InfectionsAbdominal Infections

Combination of modalities:Combination of modalities: SurgicalSurgical

Prompt drainage of abscess (secondary peritonitis) and/orPrompt drainage of abscess (secondary peritonitis) and/ordebridementdebridement

Resection of perforated colon, small intestine, ulcersResection of perforated colon, small intestine, ulcers

Repair of traumaRepair of trauma

Support of Vital functions:Support of Vital functions: Blood pressure/fluid replacementBlood pressure/fluid replacement

Monitor heart rateMonitor heart rate

Monitor urine out put (0.5 ml/kg/hr)Monitor urine out put (0.5 ml/kg/hr)

Appropriate antimicrobial therapyAppropriate antimicrobial therapy

Empiric Antibiotic TherapyEmpiric Antibiotic TherapyMUST include aerobic/anaerobic coverageMUST include aerobic/anaerobic coverage

Agents withAgents withAerobic and AnaerobicAerobic and Anaerobic activity:activity:

Ampicillin/sulbactam (Unasyn)Ampicillin/sulbactam (Unasyn) (enterococci)(enterococci)

Piperacillin/tazobactam (Zosyn)Piperacillin/tazobactam (Zosyn) ((enterococcienterococci))

Imipenem/cilistatinImipenem/cilistatin (Primaxin)(Primaxin) Meropenem (Meropenem (MerremMerrem))

ErtapenemErtapenem ((InvanzInvanz))

AminoglycosideAminoglycoside ++ clindamycinclindamycin oror metronidazolemetronidazole

TigecyclineTigecycline ((TygacilTygacil))

MoxifloxacinMoxifloxacin ((AveloxAvelox)) (active against 83% of Bacteroides strains)(active against 83% of Bacteroides strains)

(+(+ metronidazolemetronidazole: per IDSA guidelines CID 2003:37 997): per IDSA guidelines CID 2003:37 997)

Empiric Antibiotic TherapyEmpiric Antibiotic TherapyMUST include aerobic/anaerobic coverageMUST include aerobic/anaerobic coverage

(one from each of the below categories)(one from each of the below categories)

Anaerobic activity:Anaerobic activity: Chloramphenicol( also includes aerobic Gram +/Chloramphenicol( also includes aerobic Gram +/--))

Clindamycin (also includes aerobic Gram +)Clindamycin (also includes aerobic Gram +)

Metronidazole (anaerobic coverage only)Metronidazole (anaerobic coverage only)

Aerobic activity:Aerobic activity: Aminoglycosides:Aminoglycosides:

gentamicin, tobramycin (Gram negatives only)gentamicin, tobramycin (Gram negatives only)

BetaBeta--lactams:lactams:

Cefotaxime (Claforan)Cefotaxime (Claforan)

Ceftriaxone (Rocephin)Ceftriaxone (Rocephin)

Aztreonam (Azactam) (Gram negative only)Aztreonam (Azactam) (Gram negative only)

Quinolones:Quinolones:

Ciprofloxacin (Cipro) (Mostly Gram negative)Ciprofloxacin (Cipro) (Mostly Gram negative)

Levofloxacin (Levaquin) (Gram +/Levofloxacin (Levaquin) (Gram +/-- and some anaerobic coverage)and some anaerobic coverage)

MoxifloxacinMoxifloxacin ((AveloxAvelox) (Gram +/) (Gram +/-- and anaerobes)and anaerobes) Vancomycin/Linezolid/SynercidVancomycin/Linezolid/Synercid (Enterococci, MRSA)(Enterococci, MRSA)


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Spectrum of diseaseSpectrum of disease Colitis w/oColitis w/o pseudomembranepseudomembrane formationformation

Malaise, abdominal pain, water diarrhea, nausea, low feverMalaise, abdominal pain, water diarrhea, nausea, low fever PseudomembranousPseudomembranous colitiscolitis

Severe abdominal pain, perfuse diarrhea, h igh feverSevere abdominal pain, perfuse diarrhea, high fever

Symptom onset can occur shortly after startSymptom onset can occur shortly after start abxabxor several weeks afteror several weeks after txtx stoppedstopped C. diff risk ifC. diff risk if abxabx use in past 2 monthsuse in past 2 months

Diagnosis:Diagnosis: stool culture of C. diff, presence ofstool culture of C. diff, presence oftoxin A or B, endoscopytoxin A or B, endoscopy

Antibiotic Associated DiarrheaAntibiotic Associated Diarrhea Pseudomembranous colitisPseudomembranous colitis

FIRST LINE:FIRST LINE:

MetronidazoleMetronidazole (Treatment of Choice)(Treatment of Choice)

250mg PO QID or 500mg PO/IV TID x 10250mg PO QID or 500mg PO/IV TID x 10--14 days14 days

ALTERNATIVE:ALTERNATIVE: (if not responding to(if not responding to metronidazolemetronidazole ororrecurrences)recurrences)

VancomycinVancomycin

125mg PO QID x 10125mg PO QID x 10--14 days +/14 days +/-- rifampin 600mgrifampin 600mgPO BIDPO BID

Always stop the drug responsible for causing theAlways stop the drug responsible for causing theinfection as soon as possible!infection as soon as possible!

RECURRANCES:RECURRANCES:

11stst:: RetreatRetreatwith eitherwith either metronidazolemetronidazole ororvancomycinvancomycin, dosed, dosedas above, x 10as above, x 10--14d14d

>>22ndnd::Vancomycin taper/pulse therapyVancomycin taper/pulse therapy

125mg PO QID x7d, then 125mg PO BID x7d, then125mg PO QID x7d, then 125mg PO BID x7d, then125mg PO QD x7d, then 125mg PO QOD x7d, then125mg PO QD x7d, then 125mg PO QOD x7d, then125mg PO every 3 days x14d125mg PO every 3 days x14d

Can add 3 week course ofCan add 3 week course of probioticsprobiotics ((SaccharomycesSaccharomycesboulardiiboulardii 500mg PO BID) starting during final week of500mg PO BID) starting during final week oftaper and continued for 2 weeks aftertaper and continued for 2 weeks aftervancovanco tapertaper counteract disturbances & reduce risk of colonization bycounteract disturbances & reduce risk of colonization by

pathogenic bacteriapathogenic bacteria

(Per IDSA treatment guidelines)(Per IDSA treatment guidelines)

Pseudomembranous colitisPseudomembranous colitis

MetronidazoleMetronidazolevs.vs.vanomycinvanomycin Similar in nonSimilar in non--severe cases with time to resolution ofsevere cases with time to resolution of

diarrhea, side effects, and relapse ratesdiarrhea, side effects, and relapse rates

2020--25% recurrence, not related to25% recurrence, not related to txtx choice, dose orchoice, dose ordurationduration

MetronidazoleMetronidazole:: cheaper, preferred due to concern of VREcheaper, preferred due to concern of VRE

VancomycinVancomycin:: okay if pt is pregnant,


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What is the likely organism responsible?What is the likely organism responsible? E. coliE. coli ClostridiumClostridium difficiledifficile

ShigellaShigella What other info do you need about the patient?What other info do you need about the patient?

Ht and wt to calculate IBW for accurate dosingHt and wt to calculate IBW for accurate dosing txtx for C. difffor C. diff

Is this the first or recurrent episode, severity ofIs this the first or recurrent episode, severity of sxsx, pregnancy, pregnancystatus, allergies,status, allergies, ectect..

Both of the aboveBoth of the above

This is the ptsThis is the pts first episodefirst episode; what is the best antibiotic; what is the best antibiotictreatment?treatment? MetronidazoleMetronidazole 500mg PO Q 8h x14d500mg PO Q 8h x14d

VancomycinVancomycin 125mg PO or IV Q 6h x14d125mg PO or IV Q 6h x14d VancomycinVancomycin pulse/taper withpulse/taper with probioticprobiotic overlapoverlap

?????Clinical Question, cont.??????????Clinical Question, cont.????? What is the likely organism responsible?What is the likely organism responsible?

E. coliE. coli

*Clostridium*Clostridium difficiledifficile

ShigellaShigella

What other info do you need about the patient?What other info do you need about the patient? Ht and wt to calculate IBW for accurate dosingHt and wt to calculate IBW for accurate dosing txtx for C. difffor C. diff

*Is this the first or recurrent episode, severity of*Is this the first or recurrent episode, severity of sxsx, pregnancy status,, pregnancy status,allergies,allergies, ectect. (these factors influence your. (these factors influence your txtx recommendation)recommendation)

Both of the above (no, dose is not based on wt)Both of the above (no, dose is not based on wt)

This is the ptsThis is the pts first episodefirst episode; what is the best antibiotic treatment?; what is the best antibiotic treatment? **MetronidazoleMetronidazole 500mg PO Q 8h x14d (yes!)500mg PO Q 8h x14d (yes!)

VancomycinVancomycin 125mg PO or IV Q 6h x14d (IV125mg PO or IV Q 6h x14d (IVvancovanco not effective!)not effective!)

VancomycinVancomycin pulse/taper withpulse/taper with probioticprobiotic overlap (not indicated for firstoverlap (not indicated for firstepisode)episode)

?????Clinical Question, cont.??????????Clinical Question, cont.?????

ReferencesReferences

IDSA: Guidelines for the Selection of AntiIDSA: Guidelines for the Selection of Anti --infective Agents for Complicated Intrainfective Agents for Complicated Intra--abdominalabdominalInfections. CID. 2003; 37(15): 997Infections. CID. 2003; 37(15): 997--1005.1005.

Goldstein EJC,Goldstein EJC, SnydmanSnydman DR. IntraDR. Intra--abdominal infections: review of the bacteriology,abdominal infections: review of the bacteriology,antimicrobial susceptibility and role ofantimicrobial susceptibility and role of ertapenemertapenem in their therap. JAC. 2004; 53(S2):ii29in their therap. JAC. 2004; 53(S2):ii29--ii36.ii36.

MalangoniMalangoni MA, Song J, Herrington J,MA, Song J, Herrington J, ChoudhriChoudhri S,S, PertelPertel P. Randomized Controlled Trial ofP. Randomized Controlled Trial ofMoxifloxacinMoxifloxacin Compared withCompared with PiperacillinPiperacillin--TazobactamTazobactam and Amoxicillinand Amoxicillin--ClavulanateClavulanate for thefor theTreatment of Complicated IntraTreatment of Complicated Intra--abdominal Infections. Annals of Surgery. 2006; 244(2): 204abdominal Infections. Annals of Surgery. 2006; 244(2): 204--211.211.

UpToDateUpToDate. Treatment of antibiotic. Treatment of antibiotic--associated diarrhea caused by Clostridiumassociated diarrhea caused by Clostridium difficiledifficile..Accessed 3/10/2008.Accessed 3/10/2008.

UpToDateUpToDate. Anaerobic bacterial infections. Accessed 3/10/2008.. Anaerobic bacterial infections. Accessed 3/10/2008.

UpToDateUpToDate. Treatment and prophylaxis of spontaneous bacterial peritonitis. Treatment and prophylaxis of spontaneous bacterial peritonitis. Accessed. Accessed3/10/2008.3/10/2008.

UpToDateUpToDate. Appendicitis in adults. Accessed 3/10/2008.. Appendicitis in adults. Accessed 3/10/2008.

DiPiroDiPiroJT, Talbert RL, Yee GC,JT, Talbert RL, Yee GC, MatzkeMatzke GR, Wells BG, Posey ML. Pharmacotherapy: AGR, Wells BG, Posey ML. Pharmacotherapy: APathophysiologicPathophysiologicApproach, Sixth Ed. 2005.Approach, Sixth Ed. 2005.

Gilbert DN,Gilbert DN, MoelleringMoelleringRC, Eliopoulos GM,RC, Eliopoulos GM, SandeSande MA. The Sanford Guide to AntimicrobialMA. The Sanford Guide to AntimicrobialTherapy, 37Therapy, 37thth Ed. 2007.Ed. 2007.

Lin WJ, L WT, Chu C C, Chu ML, Wang CC. Bacteriology and antibiotLin WJ, L WT, Chu CC, Chu ML, Wang CC. Bacteriology and antibiot ic susceptibility ofic susceptibility ofcommunitycommunity--acquired intraacquired intra--abdominal infection in children. Jabdominal infection in children. J MicrobiolMicrobiol ImmunolImmunol Infect. 2006; 39:Infect. 2006; 39:

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