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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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Table III. Frequently isolated pathogens in complicated intra-abdominal infections
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Tab3: Table III. Frequently isolated pathogens in complicated intra-abdominal infections

Mentions: The microbiology of IAI reflects a summary of transient or persistent normal gastrointestinal flora with potentially pathogenic micro-organisms. As such, the aetiology of IAI includes Gram-positive, Gram-negative and anaerobe bacteria as well as fungal species. However, about 20–25% of cultures in secondary peritonitis prove negative.[11] In another quarter of the patients, the infection is monomicrobial and, in half of the patients peritonitis is polymicrobial.[12] However, the precise mix of pathogens involved is highly variable depending on several factors that lead to the risk profile of the patient. Table III gives an overview of the most common causative pathogens in IAI. Interpretation of the extent of micro-organisms involved is hampered by the limited microbiological workup of anaerobe cultures in general practice. In principle, IAI are polymicrobial with an aerobic component (inducing local/systemic inflammation) and an anaerobic component (responsible for abscess formation).


Essentials for selecting antimicrobial therapy for intra-abdominal infections.

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

Table III. Frequently isolated pathogens in complicated intra-abdominal infections
© Copyright Policy
Related In: Results  -  Collection

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

Tab3: Table III. Frequently isolated pathogens in complicated intra-abdominal infections
Mentions: The microbiology of IAI reflects a summary of transient or persistent normal gastrointestinal flora with potentially pathogenic micro-organisms. As such, the aetiology of IAI includes Gram-positive, Gram-negative and anaerobe bacteria as well as fungal species. However, about 20–25% of cultures in secondary peritonitis prove negative.[11] In another quarter of the patients, the infection is monomicrobial and, in half of the patients peritonitis is polymicrobial.[12] However, the precise mix of pathogens involved is highly variable depending on several factors that lead to the risk profile of the patient. Table III gives an overview of the most common causative pathogens in IAI. Interpretation of the extent of micro-organisms involved is hampered by the limited microbiological workup of anaerobe cultures in general practice. In principle, IAI are polymicrobial with an aerobic component (inducing local/systemic inflammation) and an anaerobic component (responsible for abscess formation).

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