Infection related management of complicated intra-abdominal infection (excluding appendicitis)

Publication: 09/11/2009

Next review: 18/10/2024

Clinical Guideline

CURRENT

ID: 1427

Approved By: Improving Antimicrobial Prescribing Group

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

INFECTION RELATED MANAGEMENT OF COMPLICATED INTRA-ABDOMINAL INFECTION (EXCLUDING APPENDICITIS)

Diagnostics
Empirical treatment
Duration
Review by 72
Directed therapy
Footnotes

Complicated intra-abdominal infection is defined as intra-abdominal infections that have extended beyond a hollow viscus of origin into the peritoneal space and are associated with either abscess formation or peritonitis.

DIAGNOSTICS

For patients with a presumed diagnosis of complicated intra-abdominal infection the following diagnostic tests should be taken to investigate the diagnosis further:

All patients	FBC, U&E and LFTs Blood cultures taken before empirical treatment is started Urine culture Other microbiology e.g., Intra-abdominal pus, wound swabs, sputum samples. Note: samples of pus in sterile container are preferable to swabs for recovery of pathogens
Selected patients	Radiological tests e.g. Ultrasound scan/CT scan, as clinically indicated.

EMPIRICAL TREATMENT options for complicated intra-abdominal infection

Review previous microbiology results for presence of antibiotic resistance before starting empirical therapy

	Recommended (1st line) treatment	2nd line treatment in penicillin allergy
Duration: please see table below
Empirical treatment (with sepsis)	If age < 80 Cefuroxime IV 1.5g 8-hourly AND Metronidazole PO² 400mg 8-hourly If age > 80 Piperacillin/tazobactam IV 4.5g 8-hourly	Teicoplanin IV 12mg/kg (see dosing guidance for frequency) AND Ciprofloxacin ¹ PO 500mg 12-hourly AND Metronidazole PO² 400mg 8-hourly
Empirical treatment (without sepsis) AND IV to Oral switch	Check microbiology to see if the patient has coliforms with amoxicillin-clavulanic acid resistance. If no resistance: Co-amoxiclav 625mg PO 8-hourly AND Amoxicillin 500mg PO 8-hourly	Check microbiology to see if the patient has coliforms with ciprofloxacin resistance. If no resistance: Ciprofloxacin 500mg PO 12-hourly AND Metronidazole 400mg PO 8-hourly. Teicoplanin should continue if evidence of enterococcal infection susceptible to Teicoplanin

DURATION

We advocate three antibiotic treatment duration strategies which have an evidence base to support. Assessment of a patient’s risk of treatment failure (relapse) or death may feed into consideration of which strategy to select. The choice of strategy will be best selected by a consultant/senior surgeon.

Antibiotic duration strategies	Description	Antibiotic duration
Strategy 1 - Short course	Fixed short course antibiotics in patients who responded quickly to treatment of non-severe infection	4 days treatment with good source control, 7 days without good source control.
Strategy 2 - Clinical assessment	Treat until clinical resolution of symptoms related to infection, and inflammatory markers, have improved- typically 8 to 18 days.	Based on clinical response
Strategy 3 - Fixed-extended-duration	Fixed-extended-duration antibiotic treatment of up to 4 weeks antibiotics	3 to 4 weeks.

Risk of relapse and death

Analysis of observational UK data from patients with cIAI has suggested the following factors MAY be increase a patient’s risk of relapse or death after cIAI diagnosis. These factors can be considered in the choice of antibiotic treatment strategy.

Risk of relapse	Treatment failure (failure of an initial treatment plan with the need for an unplanned source control procedure or an escalation of antibiotic therapy)
	Collections present on imaging
	Multiple and large collections
	Antimicrobial resistant infections
Risk of death	Age 65 and over
	Perforated viscus
	Cancer diagnosis

REVIEW BY 72

By 72 hours of antimicrobial treatment, diagnostics may have proven an initial diagnosis or guided to a new diagnosis. If your patient in on IV treatment this should be reviewed daily. The review, outcome and future plans (where appropriate) should be documented in the medical notes. If the diagnosis is still correct your options are now:

IVOS	If your initial diagnosis is correct and the patient is prescribed IV antibiotics, review whether an oral switch is appropriate using the ACED criteria (see below). If they meet all 4 criteria consider switching using the oral options listed in the table above. A - Afebrile for 24 hours C - Clinically improving E - Eating and drinking D- not Deep seated infection Please note that Intra-abdominal infections may commonly be classed as deep seated but depending on the antibiotic patients may still be eligible for an IVOS.
Stop	If no signs of infection and diagnostics support this decision.
Change	If the patient is not clinically responding, check microbiology results to see if directed therapy is required or you may need to consider an alternative diagnosis.
Continue	If the patient is improving but does not fully meet ACED criteria. Review daily until ready to switch. Document the reason for continuing.

DIRECTED THERAPY

Please discuss directed therapy i.e., based on culture results, with microbiology. Isolation of one bacterial species e.g., from a blood culture, may not mean intra-abdominal infection is not polymicrobial.

FOOTNOTES

Ciprofloxacin 400mg IV 12 hourly if unable to tolerate PO
Metronidazole 500mg IV 8 hourly if unable to tolerate PO

Provenance

Record:	1427
Objective:
Clinical condition:	Intra-abdominal Infection of Unknown Cause
Target patient group:	Adults
Target professional group(s):	Secondary Care Doctors Pharmacists
Adapted from:

Evidence base

Sawyer RG, Claridge JA, Nathens AB, Rotstein OD, Duane TM, Evans HL, Cook CH, O'Neill PJ, Mazuski JE, Askari R, Wilson MA, Napolitano LM, Namias N, Miller PR, Dellinger EP, Watson CM, Coimbra R, Dent DL, Lowry SF, Cocanour CS, West MA, Banton KL, Cheadle WG, Lipsett PA, Guidry CA, Popovsky K; STOP-IT Trial Investigators. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015 May 21;372(21):1996-2005.
Ahmed S, Bonnett L, Melhuish A, Adil MT, Aggarwal I, Ali W, Bennett J, Boldock E, Burns FA, Czarniak E, Dennis R, Flower B, Fok R, Goodman A, Halai S, Hanna T, Hashem M, Hodgson SH, Hughes G, Hurndalm KH, Hyland R, Iqbal MR, Jarchow-MacDonald A, Kailavasan M, Klimovskij M, Laliotis A, Lambourne J, Lawday S, Lee F, Lindsey B, Lund JN, Mabayoje DA, Malik KI, Muir A, Narula HS, Ofor U, Parsons H, Pavelle T, Prescott K, Rajgopal A, Roy I, Sagar J, Scarborough C, Shaikh S, Smart CJ, Snape S, Tabaqchali M, Tennakoon A, Tilley R, Vink E, White L, Burke D, Kirby A. Development of clinical prediction models for outcomes of complicated intra-abdominal infection. Br J Surg. 2021 Feb 22:znaa117.
Ahmed S, Brown R, Pettinger R, Vargas-Palacios A, Burke D, Kirby A. The CABI Trial: an Unblinded Parallel Group Randomised Controlled Feasibility Trial of Long-Course Antibiotic Therapy (28 Days) Compared with Short Course (≤ 10 Days) in the Prevention of Relapse in Adults Treated for Complicated Intra-Abdominal Infection. J Gastrointest Surg. 2020 Mar 5. doi: 10.1007/s11605-020-04545-2.
Montravers P, Tubach F, Lescot T, Veber B, Esposito-Farèse M, Seguin P, Paugam C, Lepape A, Meistelman C, Cousson J, Tesniere A, Plantefeve G, Blasco G, Asehnoune K, Jaber S, Lasocki S, Dupont H; DURAPOP Trial Group. Short-course antibiotic therapy for critically ill patients treated for postoperative intra-abdominal infection: the DURAPOP randomised clinical trial. Intensive Care Med. 2018 Mar;44(3):300-310.

Approved By

Improving Antimicrobial Prescribing Group

Document history

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