Antimicrobial Therapy For Intra-abdominal Infections Research Articles

Improving metronidazole prescription practices in surgical patients: a full cycle audit

IntroductionMetronidazole is commonly prescribed for intra-abdominal infections. Oral metronidazole has high bioavailability (>95%) and intravenous metronidazole should be reserved for patients not suitable for oral preparations.Methods and materialsThis full cycle...

Novel Method Suggests Global Superiority of Short-Duration Antibiotics for Intra-abdominal Infections.

Desirability of outcome ranking and response adjusted for duration of antibiotic risk (DOOR/RADAR) are novel and innovative methods of evaluating data in antibiotic trials. We analyzed data from a noninferiority trial of short-course antimicrobial therapy for intra-abdominal infection (STOP-IT), and results suggest global superiority of short-duration therapy for intra-abdominal infections.

Advances in Intra-abdominal Sepsis: What Is New?

We have reviewed the literature regarding recent advances in the management of intra-abdominal sepsis, with a focus on antimicrobial agents, duration of therapy, and source control. Several important developments in these areas are discussed in this review. The introduction of a new antimicrobial agent-ceftolozane/tazobactam-marks the first novel agent for treating intra-abdominal infections in a number of years, and its indications for use and supporting evidence are reviewed here. In addition, we discuss recent evidence that clarifies the importance of early source control for intra-abdominal infection and new data that suggests that an abbreviated course of antimicrobial therapy for intra-abdominal infection is equally effective as prolonged therapy.

Simple acute appendicitis versus non-perforated gangrenous appendicitis: is there a difference in the rate of post-operative infectious complications?

According to the 2002 Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-abdominal Infections, antimicrobial therapy is not recommended beyond 24 hours for the treatment of postoperative acute or gangrenous appendicitis without perforation. However, clinicians commonly consider gangrenous appendicitis to pose a greater risk of post-operative infectious complications, such as surgical site infections and intra-abdominal abscesses. This study examines the relative risk of post-operative infection between patients with simple and gangrenous appendicitis. A retrospective review of patients with either non-perforated gangrenous or simple appendicitis from 2010 to 2012 was performed at a large urban teaching hospital. The rate of post-operative intra-abdominal abscess formation, which was diagnosed on patient readmission to the hospital, was significantly greater in patients with non-perforated gangrenous appendicitis in comparison to those with simple non-perforated appendicitis. Also, patients with non-perforated gangrenous appendicitis received extended courses of post-operative antibiotics, despite SIS recommendations. The role of peri-operative antibiotics for non-perforated gangrenous appendicitis merits further study.

Essentials for Selecting Antimicrobial Therapy for Intra-Abdominal Infections

Intra-abdominal infection (IAI) is a complex disease entity in which different aspects must be balanced in order to select the proper antimicrobial regimen and determine duration of therapy. A current classification indicates different faces of peritonitis. Primary peritonitis implies an intact gastrointestinal tract without overt barrier disruption. Secondary peritonitis refers to localized or diffuse peritoneal inflammation and abscess formation due to disruption of the anatomical barrier. Tertiary peritonitis includes cases that cannot be solved by a single or even sequential surgical intervention, often in combination with sequential courses of antimicrobial therapy. The most frequently used classification distinguishes ‘uncomplicated’ and ‘complicated’ IAI. In uncomplicated IAI, the infectious process is contained within a single organ, without anatomical disruption. In complicated IAI, disease is extended, with either localized or generalized peritonitis. However, there exists more than a single dimension of complexity in IAI, including severity of disease expression through systemic inflammation. As the currently used classifications of IAI often incite confusion by mixing elements of anatomical barrier disruption, severity of disease expression and (the likelihood of) resistance involvement, we propose an alternative for the current widely accepted classification. We suggest abandoning the terms ‘uncomplicated’ and ‘complicated’ IAI, as they merely confuse the issue. Furthermore, the term ‘tertiary peritonitis’ should likewise be discarded, as this simply refers to treatment failure of secondary peritonitis resulting in a state of persistent infection and/or inflammation. Hence, anatomical disruption and disease severity should be separated into different phenotypes for the same disease in combination with either presence or absence of risk factors for involvement of pathogens that are not routinely covered in first-line antimicrobial regimens (Pseudomonas aeruginosa, enterococci, Candida species and resistant pathogens). Generally, these risk factors can be brought back to recent exposure to antimicrobial agents and substantial length of stay in healthcare settings (5–7 days). As such, we developed a grid based on the different components of the classification: (i) anatomical disruption; (ii) severity of disease expression; and (iii) either community-acquired/early-onset healthcare-associated origin or healthcare-associated origin and/or recent antimicrobial exposure. The grid allows physicians to define the index case of IAI in a more unequivocal way and to select the most convenient empirical antimicrobial regimens. The grid advises on the necessity of covering nosocomial Gram-negative bacteria (including P. aeruginosa), enterococci and yeasts. The basis of antimicrobial therapy for IAI is that both Gram-negative and anaerobic bacteria should always be covered.In recent years, some newer agents such as doripenem, moxifloxacin and tigecycline have been added to the antimicrobial armamentarium for IAI. For patients in whom the source can be adequately controlled, antimicrobial therapy should be restricted to a short course (e.g. 3–7 days in peritonitis).

Bowel colonization with vancomycin-resistant enterococci after antimicrobial therapy for intra-abdominal infections: observations from 2 randomized comparative clinical trials of ertapenem therapy

The impact of different antimicrobial regimens for intra-abdominal infections on the frequency of bowel colonization with vancomycin-resistant enterococci (VRE) was examined in 2 randomized open-label trials of intra-abdominal infection comparing piperacillin–tazobactam or ceftriaxone/metronidazole with ertapenem. In these short-term studies, overall rates of bowel colonization with VRE were generally comparable after treatment with piperacillin–tazobactam, ceftriaxone/metronidazole, or ertapenem.

Antimicrobial Therapy for Intra-Abdominal Infections: Guidelines from the Infectious Disease Advisory Board (IDAB)

Intra-abdominal infection is a common cause of severe sepsis in a hospital setting and remains associated with a significant morbidity, mortality and resource use.Early adequate surgery or drainage remain the cornerstones of intra-abdominal infection management and impact on patients outcome. Concomitant early and adequate empiric antimicrobial therapy further influences patients morbidity and mortality.Multiple empirical regimens have been proposed in this setting, but rarely supported by well designed, randomized-con-trolled studies. The current manuscript summarizes the recommendations of the Infection Disease Advisory Board on the management of intra-abdominal infections. Empiric antimicrobial therapy for the most common causes of abdominal infections is proposed. In addition, particular attention has been paid on antibiotic treatment duration.

The Surgical Infection Society guidelines on antimicrobial therapy for intra-abdominal infections: an executive summary.

The Surgical Infection Society last published guidelines on antimicrobial therapy for intra-abdominal infections in 1992 (Bohnen JMA, et al., Arch Surg 1992;127:83-89). Since then, an appreciable body of literature has been published on this subject. Therefore, the Therapeutics Agents Committee of the Society undertook an effort to update the previous guidelines, primarily using data published over the past decade. An additional goal of the Committee was to characterize its recommendations according to contemporary principles of evidence-based medicine. To develop these guidelines, the Committee carried out a systematic search for all English language articles published between 1990 and 2000 related to antimicrobial therapy for intra-abdominal infections. This literature was reviewed individually and collectively by the Committee, and categorized according to the type of study and its quality. Additional articles published prior to 1990 were also utilized when necessary. By a process of iterative consensus, the Committee developed provisional guidelines for antimicrobial therapy for intra-abdominal infections based on this evidence. Following extensive review by members of the Society, these guidelines were approved for publication in final form by the Council of the Surgical Infection Society. This executive summary delineates the Society's current recommendations for antimicrobial therapy of patients with intra-abdominal infections. Topics discussed include the selection of patients needing therapeutic antimicrobials, duration of antimicrobial therapy, acceptable antimicrobial regimens, and identification and treatment of higher-risk patients. Guidelines for patient selection and specific antimicrobial regimens were based on relatively good evidence, but those regarding optimal duration of therapy and treatment of higher-risk patients relied mostly on expert opinion, since there was a paucity of high-quality studies on those issues. Relevant areas for future investigation include the safety, convenience, and cost-effectiveness of available antimicrobial regimens for lower-risk patients, and better means for identifying and treating higher-risk patients with intra-abdominal infections.

The Surgical Infection Society guidelines on antimicrobial therapy for intra-abdominal infections: evidence for the recommendations.

Revised guidelines for the use of antimicrobial therapy in patients with intra-abdominal infections were recently developed by the Therapeutic Agents Committee of the Surgical Infection Society (Mazuski et al., Surg Infect 2002;3:161-173). These were based, insofar as possible, on evidence published over the past decade. The objective of this document is to describe the process by which the Committee identified and reviewed the published literature utilized to develop the recommendations and to summarize the results of those reviews. English-language articles published between 1990 and 2000 related to antimicrobial therapy for intra-abdominal infections were identified by a systematic MEDLINE search and an examination of references included in recent review articles. If current literature with regard to a specific issue was lacking, relevant articles published prior to 1990 were identified. All prospective randomized controlled trials, as well as other articles selected by the Committee, were evaluated individually and collectively. Data with regard to patient numbers, types of infections, and results of interventions were abstracted. Studies were categorized according to their design, and all included trials were graded according to quality. On the basis of this evidence, the Committee formulated recommendations for antimicrobial therapy for intra-abdominal infections and graded those recommendations. After receiving comments from invited reviewers and the general membership of the Society, the guidelines were finalized and submitted to the Council of the Surgical Infection Society for approval. The final recommendations related to the selection of patients needing therapeutic antimicrobials, acceptable antimicrobial regimens, duration of antimicrobial use, and the identification and treatment of higher-risk patients. Although numerous publications pertaining to these topics were identified, but nearly all of the prospective randomized controlled trials represented comparisons of different antimicrobial regimens for the treatment of intra-abdominal infections. A few prospective trials evaluated the need for therapeutic antimicrobial therapy in patients with peritoneal contamination following abdominal trauma. The quality of these prospective trials was highly variable. Many did not limit enrollment to patients with complicated intra-abdominal infections, lacked blinding of treatment assignment, did not provide a complete description of the criteria used to determine therapeutic success or failure, failed to identify the reasons why patients were excluded from analysis, or did not include an intention-to-treat analysis. For many issues, no prospective randomized controlled trials were encountered, and guidelines had to be formulated using evidence from studies with historical controls or uncontrolled data, or on the basis of expert opinion

New developments and concepts in antimicrobial therapy for intra-abdominal infections

Antimicrobial therapy plays an integral role in the management of intra-abdominal infections. Recent developments include increased prevalence of antimicrobial resistance (eg, Streptococcus pneumoniae and Enterococcus species) coupled with general decline in the antimicrobial susceptibility of anaerobes and gram-negative organisms, new antibiotics and dosing regimens, and better understanding of the role of various microbial pathogens and of prophylactic antimicrobial agents. Therapeutic approaches to intra-abdominal infections, such as the various forms of peritonitis, cholecystitis, cholangitis, and diverticulitis, are reviewed here. Specific recommendations for antimicrobial therapy in various clinical settings are provided, with special emphasis on recent trends and developments that reflect changes in understanding or therapy.