بروتوكول علاج العدوى البطنية الداخلية

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اطماره الجر
Ministry of Health
Intra-abdominal
Infections Treatment
Protocol
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اطماره الجر
Ministry of Health
Abbreviations
IV: Intravenous
PO: Oral
GI: Gastrointestinal
g: Gram
mg: Milligram
kg: Kilogram
dL: Deciliter
h: Hours
q24hr: Every 24 hours
q12hr: Every 12 hours
q8hr: Every 8 hours
q6hr: Every 6 hours
SCr: Serum Creatinine
TMP-SMX: Trimethoprim-sulfamethoxazole
DS: Double strength
SS: Single strength
SIRS: Systemic inflammatory response syndrome
PCN: Penicillin
MDR-GNR: Multidrug-resistant Gram-negative rods
SBP: Spontaneous bacterial peritonitis
MRSA: Methicillin-resistant Staphylococcus aureus
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السلام علي
السلام
Ministry of Health
Introduction
- Infections within the abdominal cavity typically arise because of inflammation or disruption of the gastrointestinal tract.
- Intra-abdominal infections are the second most common cause of infectious mortality in intensive care units.
- Antimicrobial therapy should be initiated once a patient receives a diagnosis of an intra-abdominal infection or once such an infection is considered likely.
- For patients without septic shock, antimicrobial therapy should be started in the emergency department.
- Satisfactory antimicrobial drug levels should be maintained during a source control intervention, which may necessitate additional administration of antimicrobials just before initiation of the procedure.
Purpose:
- In 2021 one of the most indication reported through Antimicrobial stewardship program was intra-abdominal infection at MOH hospitals
- This treatment protocol to support MOH hospitals in activating /launching / improving the antimicrobials stewardship program.
Aim and scope:
- The protocol aims to provide an evidence based, safe and cost-effective treatment guide for intrabdominal infections in the inpatient setting
- For hospital-acquired infections, the choice between the recommended agents should be based on local resistance data (i.e., the antibiogram)
Targeted population: Hospitalized immunocompetent patients who are diagnosed with Intra-abdominal infections.
Targeted end users: Physicians, pharmacists/clinical pharmacists, and nurses.
Setup: Inpatient setting.
Methodology:
These recommendations are based on the high quality of evidence along with expert opinions maintaining the best practices guidelines and taking into consideration the local resources, and cultural variation.
Conflict of interest: This protocol was developed based on valid scientific evidence, critical assessment of that evidence, and objective clinical judgment that relates the evidence to the needs of practitioners and patients.
Funding: No fund was provided
Updating: First version of this protocol created in 2022. The protocol will be updated every three years or if any changes or updates released by international/national guidelines, pharmacotherapy references or MOH formulary
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اطرف الجزء
Ministry of Health
INTRA-ABDOMINAL INFECTIONS IN ADULTS
Introduction:
Classification of Intra-abdominal infection in adults:
Two classifications are used to subdivide INTRA-ABDOMINAL INFECTIONS:
- Uncomplicated
- Complicated, considering infection extent; and community-acquired, healthcare-associated or hospital-acquired, regarding the place of acquisition.
According to the Infectious Diseases Society of America (IDSA), complicated Intra-abdominal infections is defined as an infection that extends beyond the wall of a hollow viscus of origin into the abdominal cavity while being associated with an abscess or peritonitis.
Factors indicating healthcare-associated intra-abdominal infection:
A patient is considered to have healthcare-associated intra-abdominal infection if any of the following factors is met:
1. Hospitalized for at least 48 hours during the previous 90 days
2. Residing in a skilled nursing or long-term care facility during the previous 30 days
3. Received IV infusion therapy, wound care, or renal replacement therapy within the previous 30 days
4. Received several days of broad-spectrum antimicrobial therapy within the previous 90 days
5. Have postoperative infection
6. Known to have been colonized or infected previously with a resistant pathogen
SOURCE CONTROL:
Source control should be done within 24h of diagnosis. This may include draining of infected peritoneal fluid, resection of intra-abdominal abscess, cholecystectomy (only in case of severe cholecystitis), appendectomy (only in case of severe perforated appendicitis), repair of intestinal perforation, etc.
EMPIRIC ANTIMICROBIAL THERAPY:
Empirical treatment is established by identifying whether the infection is healthcare- versus community-acquired, which organs are infected, and whether the infection is complicated or uncomplicated.
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اطرف الجزء
Ministry of Health
• HEALTHCARE-ASSOCIATED INTRA-ABDOMINAL INFECTIONS (table 1)
<table><tr><td>Regimen</td><td>Empiric antibiotic regimens for health care-associated intra-abdominal infections adults</td></tr><tr><td rowspan="3">Single agent regimen</td><td>Imipenem-cilastatin 500 mg IV q6h</td></tr><tr><td>Meropenem 1 g IV q8h</td></tr><tr><td>Piperacillin-tazobactam 4.5 g IV q6h</td></tr><tr><td rowspan="8">Combination therapy</td><td>ONE of the following:</td></tr><tr><td>Cefepime 2 g IV q8h Or</td></tr><tr><td>Ceftazidime 2 g IV q8h</td></tr><tr><td>PLUS:</td></tr><tr><td>Metronidazole 500 mg IV or PO q8h</td></tr><tr><td>PLUS ONE of the following (in some cases*):</td></tr><tr><td>Ampicillin 2 g IV q4h Or</td></tr><tr><td>Vancomycin 15 to 20 mg/kg IV q8h to q12h</td></tr></table>
* Add ampicillin or vancomycin to a cephalosporin-based regimen to provide enterococcal coverage, particularly in those with postoperative infection, prior use of antibiotics that select for Enterococcus, immunocompromising condition, valvular heart disease, or prosthetic intravascular materials.
• - COMMUNITY-ACQUIRED INFECTION (table 2)
<table><tr><td rowspan="2">Regimen</td><td colspan="2">Community-Acquired infection in Adults</td></tr><tr><td>Mild to moderate infection*</td><td>Severe infection or high risk1</td></tr><tr><td rowspan="3">Single agent</td><td>Ertapenem 1 g IV q24h</td><td>Imipenem-cilastatin 500 mg IV q6h</td></tr><tr><td>Piperacillin-tazobactam 3.375 g IV q6h</td><td>Meropenem 1 g IV q8h</td></tr><tr><td>Moxifloxacin 400 mg IV q24h</td><td>Piperacillin/tazobactam 4.5 g IV q6h</td></tr><tr><td rowspan="9">Combination therapy</td><td colspan="2">One of the following</td></tr><tr><td>Cefazolin 1 to 2 g IV q8h</td><td rowspan="2">Cefepime 2 g IV q8h</td></tr><tr><td>Cefuroxime 1.5 g IV q8h</td></tr><tr><td>Cefotaxime 2 g IV q8h</td><td rowspan="2">Ceftazidime 2 g IV q8h</td></tr><tr><td>Ceftriaxone 2 g IV q24h</td></tr><tr><td>High-risk allergy/contraindications to beta-lactams:</td><td rowspan="3">The combination of vancomycin, aztreonam, and metronidazole is an alternative for those who cannot use beta-lactams or carbapenems (e.g., because of severe allergic reactions, such as anaphylaxis, angioedema, or urticaria).</td></tr><tr><td>Ciprofloxacin400 mg IV q12h or 500 mg PO q12h</td></tr><tr><td>Levofloxacin 750 mg IV or PO q24h</td></tr><tr><td>Plus metronidazole2**500 mg IV or PO q8h</td><td>Plus metronidazole2`500 mg IV or PO q8h</td></tr></table>
*Includes perforated appendicitis, abscessed appendix, and other infections of mild to moderate severity.
** For most uncomplicated biliary infections of mild to moderate severity, the addition of metronidazole is not necessary.
\( ^{1} \) Includes severe physiologic disturbance, septic shock, older, or immunocompromised patients.
\( ^{2} \) Because of increasing resistance of Escherichia coli to fluoroquinolones, local population susceptibility profiles and isolate susceptibility should be reviewed.
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اطرف
السلاميه
Ministry of Health
NOTES:
• Microbiological cultures should be collected before the initiation of antimicrobial therapy.
- Always prefer using beta-lactam-based regimen over fluoroquinolones and aztreonam regimens unless the patient has documented severe beta-lactam allergy (such as anaphylaxis, angioedema, or urticaria). This is due to risk of emergence of bacterial resistance to fluoroquinolones.
• Coverage for methicillin-resistant Staphylococcus aureus (MRSA):
- For patients colonized with MRSA (as known by nasal swab PCR), prior treatment failure, or advanced age ( \( \geq \) 65 years).
- Use vancomycin (15 to 20 mg/kg IV every 8 to 12 hours) or teicoplanin (loading dose of 6 mg/kg every 12h for 3 doses, then maintenance dose of 6 mg/kg q24h). Alternatives: linezolid (600 mg IV or PO q12h) or daptomycin (6 to 8 mg/kg IV q24h).
• Tigecycline is not recommended for empiric therapy unless other agents are not suitable.
• Antifungal coverage: Only if fungal infection is confirmed in cultures.
- Empiric coverage should be considered in patients with recurrent gastrointestinal perforations (i.e., tertiary peritonitis).
- Anaerobic coverage (i.e., metronidazole) is not necessary for patients with community-acquired cholecystitis/cholangitis of mild-moderate severity, unless a biliary-enteric anastomosis or emphysematous cholecystitis is present.
- Definitive antimicrobial therapy should be guided by microbiological culture and susceptibility results as soon as they become available.
• Treatment based on blood cultures should be considered if the organism grew in \( \geq \) 2 blood cultures.
- Switching to oral antibiotics is acceptable after initial recovery from infection if patient can tolerate oral diet.
DURATION OF THERAPY:
- GI perforations or severe biliary infections (cholecystitis or cholangitis) operated within 12-24h do not need more than 24h of therapy post-surgery.
- In case of adequate source control (e.g., adequate drainage of infected peritoneal fluid in case of peritonitis): 4 days.
• In case of adequate source control with initial bacteremia: 7 days.
• In case of inadequate source control: 5-7 days.
- In case of failed therapy (i.e., no clinical improvement after 4-7 days of therapy): repeat diagnostic investigation and consider non-infectious conditions.
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السلام عليكم
السلام عليكم
Ministry of Health
Spontaneous Bacterial Peritonitis
- 1st line:
Ceftriaxone 2 g IV q24h
- Alternative in patients with high-risk allergy/contraindication to beta-lactams receiving fluoroquinolone prophylaxis:
Aztreonam* 2 g IV q8h + vancomycin*
- Alternative in patients with high-risk allergy/contraindication to beta-lactams NOT receiving fluoroquinolone prophylaxis:
Ciprofloxacin* 400 mg IV q8h
Prophylaxis in Patients with Cirrhosis and GI Bleeds:
- 1st line:
Ceftriaxone 1 g IV q24h
- Alternative in patients with high-risk allergy/contraindication to beta-lactams receiving fluoroquinolone prophylaxis:
Aztreonam* 1 g IV q8h + vancomycin*
- Alternative in patients with high-risk allergy/contraindication to beta-lactams NOT receiving fluoroquinolone prophylaxis:
Ciprofloxacin* 400 mg IV q12h
* For patients with severe allergy to penicillins and cephalosporins, such as anaphylaxis, angioedema, or urticaria.
Pancreatitis
• Acute Pancreatitis without Necrosis or Abscess: Antibiotics not recommended
- Acute Necrotizing Pancreatitis with Sterile Necrosis: Prophylaxis for sterile necrosis is not indicated.
- Acute Necrotizing Pancreatitis in patients with hemodynamic instability, Persistent/worsening SIRS criteria after 7-10 days off antibiotic therapy, and Acute Necrotizing Pancreatitis with Proven Infection: Start antibiotic therapy as outlined above (table 1 & 2).
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امارات الجديده
Ministry of Health
Stepdown oral therapy
<table><tr><td>If the patient is improving and tolerating oral diet. It should be guided by culture and susceptibility results (if available)</td></tr><tr><td>- Appendicitis- Cholangitis and Cholecystitis- Acute Uncomplicated Diverticulitis- Secondary Peritonitis (infection associated with perforation or spillage of GI pathogens into the peritoneal cavity)- Tertiary Peritonitis (Persistent infection associated with recurring GI perforation and/or anastomotic leakage after initial treatment for secondary peritonitis):Amoxicillin-clavulanic acid* 875 mg PO q12hORMoxifloxacin 400 mg PO q24hORMetronidazole 500mg PO q8h + Cefuroxime* 500 mg PO q12h or cephalexin 500 mg PO q6h or cefixime 400 mg PO q24h or 200 mg PO q12h or cefpodoxime 200 mg PO q12h or cefadroxil 1 g q12hHigh-risk allergy/contraindications to beta-lactams OR MDR-GNR risk:Ciprofloxacin* 750 mg PO q12h + Metronidazole 500 mg PO q8h</td></tr><tr><td>-Spontaneous Bacterial Peritonitis:Culture positive and clinically improving after 48-72h of IV therapy with oral antibiotic options feasible per culture and susceptibility resultsPatients with culture-negative SBP who are hemodynamically stable and responding (exam, lab parameters, and repeat paracentesis if performed) after 48h of empiric therapy.Oral step-down therapy options for patients with culture-negative SBP:1st line:Amoxicillin-clavulanate* 875 mg PO q12hAlternative in patients with low/medium-risk allergy to penicillins:Cefuroxime* 500 mg PO q12hHigh-risk allergy/contraindications4 to beta-lactams OR MDR-GNR risk:Ciprofloxacin* 750 mg PO q12h</td></tr><tr><td>-Prophylaxis in Patients with Cirrhosis and GI Bleeds:Patients who are hemodynamically stable and whose bleeding is controlled (no further procedures or/and transfusions needed in past 24 hours) after 48 hours of prophylaxis Oral step-down therapy:1st line:Amoxicillin-clavulanate* 500 mg PO q12hAlternative in patients with low/medium-risk allergy to penicillins:Cefuroxime* 250 mg PO q12hAlternative in patients with high-risk allergy/contraindication to beta-lactams:Ciprofloxacin* 500 mg PO q24h</td></tr></table>
*Adjust based on renal function
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اعضاء الجر
Ministry of Health
References:
- Mazuski JE, Tessier JM, May AK, et al. The surgical infection society revised guidelines on the management of intra-abdominal infection. Surg Infect (Larchmt). 2017;18(1):1-76.
- 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(2):133-164.
- Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283.
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