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Essentials for selecting antimicrobial therapy for intra-abdominal infections.

Blot S, De Waele JJ, Vogelaers D - Drugs (2012)

Bottom Line: 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 advises on the necessity of covering nosocomial Gram-negative bacteria (including P. aeruginosa), enterococci and yeasts.In recent years, some newer agents such as doripenem, moxifloxacin and tigecycline have been added to the antimicrobial armamentarium for IAI.

View Article: PubMed Central - PubMed

Affiliation: Faculty of Medicine & Health Sciences, Ghent University, Ghent, Belgium. stijn.blot@UGent.be

ABSTRACT
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).

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Fig. 1 Initial culture results in secondary and tertiary peritonitis: percentages of positive cultures according to the primary source of infection.[19]
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Fig1: Fig. 1 Initial culture results in secondary and tertiary peritonitis: percentages of positive cultures according to the primary source of infection.[19]

Mentions: Location of the primary source of secondary peritonitis influences the spectrum of pathogens involved, as stomach, upper small bowel, lower small bowel and large bowel have a distinct flora in terms of microbial species and density. Figure 1 summarizes initial culture results, according to the primary source of the IAI as found by de Ruiter et al.[19] There exists a preponderance of Gram-negative and anaerobic bacteria in IAI originating from colorectal sources or appendicitis. In gastro-duodenal perforation, Gram-positive bacteria and yeasts are isolated most frequently. In IAI from a small intestine source, there is a relative balance between the four different groups of pathogenic micro-organisms. However, in subsequent weeks there is a shift in culture results, showing an increase in Gram-positive bacteria, while the prevalence of Gram-negatives decreases.[19]


Essentials for selecting antimicrobial therapy for intra-abdominal infections.

Blot S, De Waele JJ, Vogelaers D - Drugs (2012)

Fig. 1 Initial culture results in secondary and tertiary peritonitis: percentages of positive cultures according to the primary source of infection.[19]
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3585770&req=5

Fig1: Fig. 1 Initial culture results in secondary and tertiary peritonitis: percentages of positive cultures according to the primary source of infection.[19]
Mentions: Location of the primary source of secondary peritonitis influences the spectrum of pathogens involved, as stomach, upper small bowel, lower small bowel and large bowel have a distinct flora in terms of microbial species and density. Figure 1 summarizes initial culture results, according to the primary source of the IAI as found by de Ruiter et al.[19] There exists a preponderance of Gram-negative and anaerobic bacteria in IAI originating from colorectal sources or appendicitis. In gastro-duodenal perforation, Gram-positive bacteria and yeasts are isolated most frequently. In IAI from a small intestine source, there is a relative balance between the four different groups of pathogenic micro-organisms. However, in subsequent weeks there is a shift in culture results, showing an increase in Gram-positive bacteria, while the prevalence of Gram-negatives decreases.[19]

Bottom Line: 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 advises on the necessity of covering nosocomial Gram-negative bacteria (including P. aeruginosa), enterococci and yeasts.In recent years, some newer agents such as doripenem, moxifloxacin and tigecycline have been added to the antimicrobial armamentarium for IAI.

View Article: PubMed Central - PubMed

Affiliation: Faculty of Medicine & Health Sciences, Ghent University, Ghent, Belgium. stijn.blot@UGent.be

ABSTRACT
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).

Show MeSH
Related in: MedlinePlus