Phar 352 - Intra-Abdominal Infections

Front 1

Where is the peritoneal cavity?

Back 1

Extends from undersurface of diaphragm to the floor of the pelvis

Front 2

What does the peritoneal cavity normally contain?

Back 2

50ml sterile serous fluid, low in protein, leukocytes and no fibrinogen

Front 3

What does the normal GI microflora of the stomach consist of?

Back 3

H.pylori, Streptocci and Lactobacilli [Total bacterial count 0-10^8]

Front 4

What does the normal GI microflora of the Upper Small Intestine consist of?

Back 4

Lactobacilli, Streptocci, Staphylocci, Enterocci, Enterobacteriae (E.coli, Klebsiella, Enterobacter) [Total bacterial count 0-10^5]

Front 5

What does the normal GI microflora of the Lower Small Intestine consist of?

Back 5

Aerobes: Enterobacteriae (E.coli, Klebsiella, Enterobacter) Lactobacilli, Staphylocci Anaerobes: Bacteriodes (B.fragilis, B.thetaiotamicron, B.vulgatus)

Front 6

What does the normal GI microflora of the Large Intestine consist of?

Back 6

Aerobes: Lactobacilli, Streptocci, Staphylocci, Enterocci, Enterobacteriacae (E.coli, Klebsiella, Enterobacter) Anaerobes: Bacteriodes (B.fragilis, B.thetaiotamicron, B.vulgatus) Pseudomonas aeruginosa, Candida

Front 7

How do Aerobes set up the ideal environment for Anaerobes? (i.e. Bacterial Synergism)(3)

Back 7

1) Consumes O2 providing an anerobic environment

2) Produces waste used as nutrients by anaerobes

3) Produces enzymes which promote anaerobic tissue invasion

Front 8

What are the signs and symptoms of fairly systemic intra-abdominal infections?

Back 8

1) Fever/Chills

2) Nasuea/Vomitting

3) Abdominal Pain

4) Tenderness

5) Guarding

6) Decreased Bowel Sounds

Front 9

What organs are in the Right Upper Quadrant?

Back 9

Liver, Gall Bladder

Front 10

What organs are in the Left Upper Quadrant?

Back 10

Pancreas

Front 11

What organs are in the Right Lower Quadrant?

Back 11

Appendix

Front 12

What is "Rebound Tenderness"?

Back 12

Pain felt when pressure is applied to the abdomen and is suddenly released

Front 13

What is "Guarding"?

Back 13

Abdominal wall muscle spasm (Patient does not want you near them)

Front 14

What are the Lab Values of Intra-Abdominal Infections?

Back 14

1) Increased PMN cells (>300/mm^3) shifted to the left

2) pH <7.35

3) Positive for Lactate

4) Positive for Protein

5) Positive for Gram Stain

Front 15

What is the frequency of occurrence for Primary Peritonitis?

Back 15

Relatively uncommon

1) 10-25% of patients with ascites related to alcoholic cirrhosis

2) Risk increases with PPI

Front 16

What is the frequency of occurrence for Peritoneal Dialysis Related Peritonitis?

Back 16

1) 60% of patients with chronic ambulatory peritoneal dialysis will have 1 episode in 1st year 2) Avg incidence in CAPD pts is 1.3-1.4 episodes per year

Front 17

What is the frequency of occurrence for Intra-Abdominal Abscess?

Back 17

Commonly seen in Appendicitis, Diverticulitis, Pancreatis, female GU tract. [Can take days-years to form]

Front 18

What is the frequency of occurrence for Acute Choleocystitis?

Back 18

Higher risk with

1) Gallstones

2) Tumors

3) Bile duct blockage

Front 19

What are the typical causative organisms of Primary Peritonitis?

Back 19

Source is usually outside peritoneal cavity

1) E.coli (65%)

2) Klebsiella pneumoniae (15%)

3) Strep pneumonae (15%)

4) Anaerobes (<1%)

Front 20

What are the typical causative organisms of Peritoneal Dialysis Related Peritonitis?

Back 20

Source is usually outside peritoneal cavity

1) Staph Aureus (4%)

2) Staph Epidermidis (8%)

Front 21

What are the typical causative organisms of Secondary Peritonitis?

Back 21

Source is usually within the peritoneal cavity usually GI tract

1) E.coli (56-66%)

2) Proteus (11-26%)

3) Klebsiella (8-29%)

4) Streptocci (12-47%)

5) B.fragilis (40-93%)

6) Enterococcus

7) Candida

Front 22

What are the typical causative organisms of Intra-Abdominal Abscess?

Back 22

Anaerobes - Bacteriodes (B.fragilis)

Front 23

What are the typical causative organisms of Acute Appendicitis?

Back 23

Source is usually within the peritoneal cavity usually GI tract

1) E.coli (56-66%)

2) Proteus (11-26%)

3) Klebsiella (8-29%)

4) Streptocci (12-47%)

5) B.fragilis (40-93%)

6) Enterococcus

7) Candida

Front 24

What are the typical causative organisms of Acute Choleocystitis?

Back 24

1) Enterobacteriacae

2) Enterococcus

3) Anaerobes

Front 25

What are the typical causative organisms of Acute Cholangitis?

Back 25

1) Enterobacteriacae

2) Enterococcus

3) Anaerobes

Front 26

What are the Treatment Options of Primary Peritonitis?

Back 26

Usually only requires antibiotics but no surgical intervention:

-Treat for 10 days if blood culture is +ve, and 5-7 days if blood culture is -ve

Front 27

What are the Treatment Options of Peritoneal Dialysis Related Peritonitis?

Back 27

Usually only requires antibiotics, IntraPeritoneal (IP) is superior to IV. [Watch for Abscess], and consider catheter removal.

Front 28

What are the Treatment Options of Secondary Peritonitis?

Back 28

Usually one requires antibiotics, consider treating If Enterococcus or Candida

Front 29

When would you consider treating Enterococcus in Secondary Peritonitis?

Back 29

1) Health care infections 2) Distal colon surgery 3) Hepatobilliary/pancreatic infection

4) Valvular disease 5) Prosthetic Heart Valve

6) Chronic/Immunocompromised

7) Previous Ab Use

8) If Enterococcus is the predominant organism in culture

Front 30

When would you consider treating Candida in Secondary Peritonitis?

Back 30

Positive gram stain AND one of the following:

1) Intracellular yeast/hyphae

2) Immunocompromised

3) Multiple previous Abx

4) GI perforations

5) Post-operative abdominal infections

6) Recurrent IA infection

Front 31

What are the Treatment Options of Intra-Abdominal Abscess?

Back 31

Should only use IntraPeritoneal antibiotics since PO does not penetrate well. Should drain the abscess. [Ultrasound or CT scan may be used to evaluate the severity]

Front 32

What are the Treatment Options of Uncomplicated Acute Appenicitis?

Back 32

Empiric Therapy is Unnecessary. Surgical prophylaxis is recommended.

Front 33

What are the Treatment Options of Complicated Acute Appenicitis?

Back 33

Empiric Therapy is Necessary

Front 34

What are the Treatment Options of Acute Choleocystitis?

Back 34

Mild cases do not require Antibiotics. Therapy is usually 7 days [3-5 days if no perforation, abscess or cholangitis]

{Don't cover Enteroccous unless elderly, immunocompromised, diabetic, bile duct obstructions}

Front 35

What are the step-down criteria for IP/IV step-down criteria to PO?

Back 35

1) Able to tolerate oral medications

2) Afebrile

3) Normal WBC count

4) No residual fluid collection

5) Return of GI functions

Front 36

What are the Surgical Options for Intra-abdominal infections?

Back 36

1) Prompt drainage of abscess and/or debridement

2) Resection of perforated colon, small intestine, ulcers

3) Repair Trauma

Front 37

What are the Vital Functions Support infections?

Back 37

1) Blood pressure/fluid replacement

2) Monitor heart rate

3) Monitor urine output (0.5mL/kg/hr)

Front 38

What are the typical Monitoring Parameters for Intra-Abdominal Infections?

Back 38

Re-check ascitic fluid at 48hrs:

1) Fluid is sterile

2) WBC<250/mm^3

3) Decreased Protein

4) Negative Culture

5) Patient feels clinically well

Front 39

What is the DOC for Primary Peritonitis?

Back 39

Ceftriaxone or Cefotaxime

Front 40

What is the DOC for Peritoneal Dialysis Related Peritonitis?

Back 40

Cefazolin (15mg/kg) IP + Gentamicin (0.6mg/kg) IP once a day

Front 41

What is the DOC for Secondary Peritonitis (mild-mod)?

Back 41

3rd Gen Cephalosporin : Ceftriaxone (1-2g IV daily) + Metronidazole (500mg IV/PO BID) {other cephalosporins include Cefotetan, Cefoxitin, Ceftriazone}

Front 42

What is the DOC for Secondary Peritonitis (severe)?

Back 42

Piperacillin /Tazobactam (4.5g IV q8h) ± Gentamicin (7mg/kg IV q24h) {Use AMG if septic shock, recent Abx use, ESBL/Carbaperamase organism}

Front 43

What is the DOC for Acute Choleocystitis?

Back 43

3rd Gen Cephalosporin : Ceftriaxone (1-2g IV daily) + Metronidazole (500mg IV/PO BID) {other cephalosporins include Cefotetan, Cefoxitin, Ceftriazone}

Front 44

What is the DOC for Acute Cholangitis?

Back 44

Piptazo 4.5g IV q8h (or 3.375g IV q6h)

Front 45

What are the alternative drug therapies for Primary Peritonitis?

Back 45

1) Ampicillin+Gentamicin

2) Cefazolin+Gentamicin

3) Piperacillin/Tazobactam

4) Ertapenem

5) Imipenem or Meropenem

6) Fluroquinolones

Front 46

What are the alternative drug therapies for Peritoneal Dialysis Related Peritonitis?

Back 46

1) Vancomycin (15mg/kg IP q7 days) + Gentamicin (0.6mg/kg IP daily) {can add cefazolin if very bad}

[Ciprofloxacin is no longer recommended due to high resistance]

Front 47

Why do you never recommend Cefazolin and Ceftazodime together?

Back 47

They are antagonistic

Front 48

What are the alternative drug therapies for Secondary Peritonitis (mild-mod)?

Back 48

1) Ciprofloxacin (400mg IV BID) + Metronidazole (500mg IV/PO BID)

2) Levofloxacin + Metrondazole

3) Ertapenem (1g IV q24hrs)

4) Moxifloxacin (400mg IV q24hrs)

5) Ampicillin (2g IV q6hrs) + Gentamicin (5-7mg/kg IV q24hrs) + Metronidazole (500mg IV/PO BID)

Front 49

What are the alternative drug therapies for Secondary Peritonitis (severe)?

Back 49

1) Imipenem (500mg IV q6hrs) ± AMG

2) Meropenem (500mg IV q6hrs)(1g IV q8hrs) ±AMG

Front 50

What are the alternative drug therapies for Acute Cholecocystitis?

Back 50

1) Ciprofloxacin (400mg IV BID) + Metronidazole (500mg IV/PO BID)

2) Levofloxacin + Metrondazole

3) Ertapenem (1g IV q24hrs)

4) Moxifloxacin (400mg IV q24hrs)

5) Ampicillin (2g IV q6hrs) + Gentamicin (5-7mg/kg IV q24hrs) + Metronidazole (500mg IV/PO BID)

Front 51

What are the alternative drug therapies for Acute Cholangitis?

Back 51

1) Imipenem (500mg IV q6h)

2) Meropenem (500mg IV q6h/ 1g IV q8h)

3) Ertapenem (1g IV q24h)

4) Ceftriaxone (1-2g IV daily) ± Metronidazole (500mg IV/PO BID)

5) Vancomycin (15mg/kg IV q12h) + Ciprofloxacin (400mg IV/500mg PO BID) ± Metronidazole (500mg IV/PO BID)