Severe Intra-Abdominal Infection Modul

Severe Intra-abdominal Infection

Anatomy and Physiology

• The peritoneum is the largest and most complexly arranged serous membrane in the body.

• The potential peritoneal spaces, the peritoneal reflections forming peritoneal ligaments, mesenteries, omenta and the natural flow of peritoneal fluid determine the route of spread of intraperitoneal fluid and, consequently, disease processes within the abdominal cavity.

Healy, J. C.; et al. 1998. The peritoneum, mesenteries and omenta: normal anatomy and pathological processes. European Radiology

Abdominal Organs

Anterior Lateral

Introduction

• Intra-abdominal infection (IAI) is an important cause of morbidity and mortality

• the second most commonly identified cause of severe sepsis in the intensive care unit (ICU)

• Most IAI are a result of processes involving inflammation and perforations of the gastrointestinal tract, such as appendicitis, peptic ulcer disease, and diverticulitis.

Lopez, Nicole, et al. 2011. A Comprehensive review of abdominal infections. World Journal of Emergency Surgery

Definition

• IAI include the following pathological conditions:– Infections of single organs (cholecystitis,

appendicitis, diverticulitis, cholangitis, pancreatitis, salpingitis, etc.), which can be or not be complicated by peritonitis even in the absence of perforation

– Peritonitis (primary, secondary or tertiary)– Intra-abdominal abscesses classified on the basis

of their location and anatomic configuration.• Menichetti, F.; Et Al. 2009. Definition And Classification Of Intra-abdominal Infections.

Journal Of Chemotherapy.

Epidemiology

• Intra-abdominal infections are common in clinical practice and comprise a wide variety of clinical presentations and differing sources of infection. The infections can involve the entire peritoneal cavity or retroperitoneal spaces, or can be localized with one or more abscesses surrounding diseased or perforated viscera.

http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm324083.htm

Classification

Peracci, F.M. et al. 2007. Management Of Severe Sepsis Of Abdominal Origin. Scandinavian Journal of Surgery.

Classification

• Uncomplicated abdominal infections the infectious process is contained within a single organ

• Complicated abdominal infections (cIAI) disease is extended, with either localized or generalized peritonitis– Primary peritonitis, Secondary peritonitis, Tertiary

peritonitis, & Intra-abdominal sepsis– 2 types : Community (can be mild or serious) & Hospital

cIAI (usually occur as post-operative infections)

• Lopez, Nicole, et al. 2011. A Comprehensive review of abdominal infections. World Journal of Emergency Surgery• Menichetti, F.; Et Al. 2009. Definition And Classification Of Intra-abdominal Infections. Journal Of Chemotherapy.• Blot, Stijn. Et al. 2012. Intra-Abdominal Infections. Drugs

Classification

• Peritonitis : IAI in which the local inflammatory process is caused by bacteria, fungi or their toxins and can be considered equivalent to sepsis located in the abdominal cavity– Primary peritonitis : This is diffused bacterial peritonitis without organ

perforation, almost always with a monomicrobial etiology, subdivided into :• Spontaneous peritonitis in children• Spontaneous peritonitis in cirrhotic adults• Peritonitis in patients on chronic peritoneal dialysis (CAPD)• Tuberculous and other granulomatous forms of peritonitis

• Menichetti, F.; Et Al. 2009. Definition And Classification Of Intra-abdominal Infections. Journal Of Chemotherapy.

Classification– Secondary peritonitis : This is local (often abscesses) or diffused peritonitis

originating from a defect in the wall of abdominal organs, 3 different categories :1. Acute peritonitis from perforation or acute inflammation of endoabdominal organs

(community-acquired) due to:– Perforation and/or acute inflammation of endoabdominal organs– Intestinal ischemia– Pelvic peritonitis– Bacterial translocation

2. Post-operative peritonitis (nosocomial) due to:– Anastomotic surgical dehiscence– Accidental perforation and devascularization– Intestinal suture dehiscence– Intestinal surgical stump dehiscence

3. Post-traumatic peritonitis after:– Closed abdominal trauma– Open abdominal trauma


Classification

– Tertiary peritonitis : late peritonitis syndromes which occur after a form of secondary peritonitis which has been treated surgically and they are associated with a peritoneal cavity which is sterile or contaminated by microorganisms of low pathogenicity, classified into categories:• Peritonitis without evidence of pathogens• Peritonitis of fungal etiology• Peritonitis caused by bacteria of low pathogenicity


Classification

Intra-abdominal abscess• Intra-abdominal abscess can be classified on the basis of

its location :1. Intraperitoneal abscess can be divided into the following

categories:• Subphrenal, Subhepatic, Retrocavity of the epiloon, Pelvic, Paracolic,

& Mesenteric (between the folds)

2. Retroperitoneal abscess3. Parenchymal abscess

• Hepatic, Splenic, Pancreatic, & Renal

• Abscesses can occur in solitary, multiple or multilocalized form


Secondary peritonitis

a. Perforated liver abscess b. Fibrin on small bowel loops.

(Image source: Clinic for Emergency Surgery, Clinical Center of Serbia, Belgrade, Serbia)

Secondary peritonitis

c. Colon perforation d. Infected pancreatic necrosis.

(Image source: Clinic for Emergency Surgery, Clinical Center of Serbia, Belgrade, Serbia)

Etiology

Herzog , T., et al. 2010. Treatment of Complicated Intra-abdominal Infections In The Era of Multi-drug Resistant Bacteria. Eur J Med Res.

Peracci, F.M. et al. 2007. Management Of Severe Sepsis Of Abdominal Origin. Scandinavian Journal of Surgery.

Etiology

Lopez et al. World Journal of Emergency Surgery 2011Herzog , T., et al. 2010. Treatment of Complicated Intra-abdominal Infections In The Era of Multi-drug Resistant Bacteria. Eur J Med Res.

Cause of peritonitis

Clinical Features• Abdominal pain

– Acute or insidious– Initially, the pain may be dull and poorly localized (visceral peritoneum) and often

progresses to steady, severe, and more localized pain (parietal peritoneum).• SIRS manifestations: Core

– Body temperature > 38°C or < 36°C, – heart rate > 90 beats per minute, – respiratory rate > 20 breaths per minute (not ventilated) or PaCO2 < 32 mm Hg

(ventilated),– WBC > 12,000, < 4,000 or > 10% immature forms (bands)

• Hypotension and hypoperfusion signs such as lactic acidosis, oliguria, and acute alteration of mental status indicative of evolution to severe sepsis

• Abdominal rigidity suggest peritonitis

Sartelli, Massimo. 2010. A focus on intra-abdominal infections. World Journal of Emergency Surgery

Diagnosis

1. Microbiological : blood cultures, gram stain2. Radiological : Definitive diagnostic3. AXR– look for free gas, bowel obstruction, or subtle signs

of intestinal ischaemia– water-soluble contrast studies can show leaks– injection of contrast into drains, fistulae or sinus

tracts may help demonstrate anatomy of complex infectious and help monitor adequacy of abscess drainage

http://www.aic.cuhk.edu.hk/web8/Intra-abdo%20infection.htm

Diagnosis

4. USG– helpful in the evaluation of right upper quadrant

(e.g. perihepatic abscess, cholecystitis, pancreatitis), right lower quadrant, and pelvic pathology (e.g. appendicitis, tubo-ovarian abscess, Douglas abscess)

– Limitation : patient discomfort, abdominal distension, and bowel gas interference


Diagnosis

5. Computed tomography (CT) – When patients are stable– diagnostic study of choice for intra-abdominal

infections– can detect small quantities of fluid, areas of

inflammation, and other GI tract pathology, with a very high sensitivity


Management

• Successful treatment of IAI is based on early and appropriate physiological resuscitation, systemic antibiotics, source control

• The most important of these factors is source control

• three key components of source control: drainage, debridement, and definitive management

Lopez, Nicole, et al. 2011. A Comprehensive review of abdominal infections. World Journal of Emergency Surgery

Management

• Drainage – The goal : to evacuate purulent, contaminated fluid, or

to control drainage of ongoing enteric contamination. This is accomplished by either percutaneous or open surgical intervention

• Debridement – Essential for removal of foreign bodies, fecal matter,

hematoma, and infected or necrotic tissue.• Definitive management involves restoration of

anatomy and function.

Antimicrobial therapy

• Antimicrobial therapy plays an integral role in the management of intra-abdominal infections.

• The choice of an inadequate antimicrobial agent is a cause of therapeutic failure.

• Once the diagnosis of complicated intra-abdominal infection is suspected, it is appropriate to begin empiric antimicrobial therapy before an exact diagnosis is established and before results of appropriate cultures are available.

Treatment of PeritonitisType of Peritonitis

Pathogens Treatment

Primary E.coli, Klebsiella sp, pneumococci

Antibiotics aloneMust be sure of the diagnosisNo anaerobs and not a polymicrobial infection

Secondary

Enteric gram-negatives and obilgate anaerobs

Surgical source controlDrainage and debridement of peritoneal cavityAntibiotics against pathogens

Tertiary Resistant gram-negatives (e.g Pseudomonas sp) enterococci, Candida sp

Mechanical debridementFrequent reoperationsMeticulous wound careAntimicrobial therapy

Donald E.Fry : Peritonitis: Management of the Patient with SIRS and MODS,2000

Potential ICU Problems and Their Solution

Scenario Problem Diagnosis Current Therapy

Solution

A.Secondary Peritonitis

Fever (T 38oC) WBCPatient look sick

Initial cultures E.coli, Bacteroides fragilis & ESBL-producing EnterobacterInfiltration on chest X-raypO2

Combined Ampicillin, Gentamycin and Metronidazole

Discontinue initial antibioticsCommence Meropenem + CiprofloxacinAbd-CT catheter or operative drainConsider bronchoscopic broncholaveoloar lavage

B. Secondary Peritonitis

StableCT shows two small undrainable loculi

No cultures obtainedPresume anaerob (polymicrobial)

Cefotaxime + Metronidazole

Meropenem +/- VancomycinConsider Fluconazole

C.Secondary Peritonitis

Some or all the aboveOral candidosisAscites

Growth of candida albicans from multiple sites (possible invasive candidosis)

Combined Ampicillin, Gentamycin and Metronidazole

Adding FluconazolePossibly change to Meropenem +/- Gentamycin

Scenario Problem Diagnosis Current Therapy

Solution

D. Blunt Abdominal TraumaPerforated small bowel and colonRuptured spleen

Diffuse faecal spill3 h in duration1000 ml bloodloss

Mixed colonic flora contamination

- Primary resection and anastomosis x3Extensive peritoneal irrigationMeropenem or Imipenem Therapy (possibly for 7 days)

E.Seventh day of acute pancreatitis

Fever & WBCCT shows single large lesser sac collectionAspirate reveals gr(-) bacilli

Infected peripancreatic collection

None CT-guided catheter drainage or open operative debridement and drainageMeropenem +/- Vancomycin

F.Scenario E, now 6 days post drainage Deteriorating

Repeat CT shows incompletely drain collection

Inadequately drained or recurrent peripancreatic sepsis

Imipenem

Operative debridement and redrainageUpper abdominal wound left open for daily repackingAdd Fluconazole

Smith et al : The Surgeon’s Guide to Antimicrobial Therapy, 2000


Lopez et al. World Journal of Emergency Surgery 2011


Herzog , T., et al. 2010. Treatment of Complicated Intra-abdominal Infections In The Era of Multi-drug Resistant Bacteria. Eur J Med Res.


Eckmann, C., et al. 2011.Antimicrobial Treatment Of „Complicated“ Intra-abdominal Infections And The New Idsa Guidelines – A Commentary And An Alternative European Approach According To Clinical Definitions. Eur J Med Res.











Empiric Antibiotic Therapy

Armstrong, Carrie. 2010.Updated Guideline on Diagnosis and Treatment of Intra-abdominal Infections . Clinical Infectious Diseases,

Prognosis• Early prognostic evaluation of complicated intra-abdominal

infections is important to assess the severity and the prognosis of the disease.

• Factors influencing the prognosis of patients with complicated intra-abdominal infections include – advanced age, – poor nutrition, – pre-existing diseases, – immunodepression, – extended peritonitis, – occurrence of septic shock, – poor source control, – organ failures, – prolonged hospitalization before therapy, and – infection with nosocomial pathogens

Lopez et al. World Journal of Emergency Surgery 2011

Prognosis

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Severe Intra-Abdominal Infection Modul