Guidelines for the Selection of Anti-infective Agents for Complicated Intra-abdominal Infections
Joseph S. Solomkin
2
4
John E. Mazuski
1
2
Ellen J. Baron
0
2
Robert G. Sawyer
2
8
Avery B. Nathens
2
7
Joseph T. DiPiro
2
5
6
Timothy Buchman
1
2
E. Patchen Dellinger
2
7
John Jernigan
2
10
Sherwood Gorbach
2
9
Anthony W. Chow
2
11
John Bartlett
2
3
0
Department of Microbiology, Stanford University School of Medicine
, Palo Alto,
California
1
Department of Surgery, Washington University School of Medicine
,
St. Louis, Missouri
2
Received 30 June 2003; accepted 30 June 2003;
electronically published 25 September 2003. These guidelines were developed and issued on behalf of the Infectious Diseases Society of America. of Cincinnati College of Medicine
, 231 Albert B. Sabin Way, Cincinnati,
OH 45267- 0558
3
Department of Medicine, Johns Hopkins University School of Medicine
,
Baltimore, Maryland
4
Department of Surgery, University of Cincinnati College of Medicine
, Cincinnati,
Ohio
5
Department of Surgery, Medical College of Georgia
, Augusta
6
University of Georgia College of Pharmacy
7
Department of Surgery, University of Washington
,
Seattle
8
Department of Surgery, University of Virginia
,
Charlottesville
9
Department of Medicine, Tufts University School of Medicine
,
Boston, Massachusetts
10
Centers for Disease Control and Prevention
,
Atlanta
11
Department of Medicine, University of British Columbia
,
Vancouver
,
British Columbia
,
Canada
Treatment Guidelines for Intra-abdominal Infections CID 2003:37 (15 October) 997
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EXECUTIVE SUMMARY
These guidelines, from the Infectious Diseases Society
of America (IDSA), the Surgical Infection Society, the
American Society for Microbiology, and the Society of
Infectious Disease Pharmacists, contain evidence-based
recommendations for selection of antimicrobial therapy
for adult patients with complicated intra-abdominal
infections. Complicated intra-abdominal infections
extend beyond the hollow viscus of origin into the
peritoneal space and are associated either with abscess
formation or with peritonitis. These guidelines also
address timing of initiation of antibiotic therapy, when
and what to culture, modification of therapy based on
culture results, and duration of therapy.
Infecting flora. The anticipated infecting flora in
these infections and, therefore, the agent(s) selected are
determined by whether the infection is community
acquired or health care associated. Health careassociated
intra-abdominal infections are most commonly
acquired as complications of previous elective or
emergent intra-abdominal operations and are caused by
nosocomial isolates particular to the site of the
operation and to the specific hospital and unit.
For community-acquired infections, the location of
the gastrointestinal perforation (stomach, duodenum,
jejunum, ileum, appendix, or colon) defines the
infecting flora. Established infection beyond the proximal
small bowel is caused by facultative and aerobic
gramnegative organisms; infections beyond the proximal
ileum also can be caused by a variety of anaerobic
microorganisms.
Microbiologic evaluation. Given the activity of
common regimens against the anaerobic organisms
identified in community-acquired infections,
microbiologic workup for specimens from such infections
should be limited to identification and susceptibility
testing of facultative and aerobic gram-negative bacilli.
Susceptibility profiles for Bacteroides fragilis group
isolates demonstrate substantial resistance to clindamycin,
cefotetan, cefoxitin, and quinolones, and these agents
should not be used alone empirically in contexts in
which B. fragilis is likely to be encountered.
Recommended regimens. These infections may be
managed with a variety of single- and multiple-agent
regimens. The antimicrobials and combinations of
antimicrobials listed in table 1 are considered appropriate
for the treatment of community-acquired
intra-abdominal infections. No regimen has been consistently
demonstrated to be superior or inferior. Although many of
the listed regimens have been studied in prospective
clinical trials, many such studies have serious design
flaws. Recommendations are, therefore, based in part
on in vitro activities.
Recommended agents for treatment of community-acquired complicated intra-abdominal infections.
Type of therapy
Carbapenems Combination regimen Cephalosporin based Fluoroquinolone based
Monobactam based
Agent(s) recommended for
mild-to-moderate infections
Agent(s) recommended for
high-severity infections
Ampicillin/sulbactam,a ticarcillin/clavulanic acid
Piperacillin/tazobactam
Ertapenem Imipenem/cilastatin, meropenem Cefazolin or cefuroxime plus metronidazole Ciprofloxacin, levofloxacin, moxifloxacin
or gatifloxacin, each in combination
with metronidazoleb
Third/fourth-generation cephalosporin (cefotaxime,
ceftriaxone, ceftizoxime, ceftazidime, cefepime)
plus metronidazole
Ciprofloxacin in combination with metronidazole
Aztreonam plus metronidazole
a Because increasing resistance of Escherichia coli to ampicillin and to ampicillin/sulb (...truncated)