ID: Intra-Abdominal Infections
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Why does stomach have fewer bacteria?
- gastric motility
- bactericidal activity (acidic pH 1-2)
What kind of flora do duodenum and jejunum harbor?
- oral flora
- (streptococcus, lactobacillus)
For lower small intestine, what kind of bacteria does ileum harbor?
how about distal ileum?
- ileum: facultative GN, GP, obligate anaerobes
- distal ileum: anaerobe
bacteria in large bowel? distal colon?
- mainly bacteroides
2 kinds of biliary tract infection
- presence of cholelithiasis
biliary tract infection is mostly ___ infection.
S&S of biliary tract infection
2 BTIs are cholecystitis adn cholangitis
- RUQ pain, abdominal distention
- anorexia, NV
- fever, shaking chils
labs of bilirary tract infection
- inc bilirubin, alk phos, aminotransferase
cholecystitis is inflam of __
gallstone in cholecystitis can result in...
- increased intraluminal pressure
- gallbladder distention
abx for community acquired mild-mod cholecystitis
- cefazolin (1st)
- cefuroxime (2nd)
- ceftriaxone (3rd)
- no need to cover anaerobe
abx for nosocomial or community-severe, adv age, immunocompromised cholecystitis?
- imi, mero, dori (not erta)
- cipro, levo, or cefepime + metronidazole
- (unlike comm-acq mild-mod, need to consider anaerobe)
cholangitis is inflam of ___
common bile duct
important difference btwn cholestitis vs. cholangitis
cholangitis has bloodstream infection
microbiology of biliary tract
- GN (e coli, kleb)
- GP (streptococc)
how to treat biliary tract?
- ultrasonography if suspected
- early surgical
- no PO intake
- NG suction
- IV fluids & electrolytes
do you need anaerobic therapy for biliary tract?
no, unless bilirary enteric anastamosis (benign stricture)
should i cover enterococcus for bilirary tract?
- not required
- except immunosuppressed pts
do i need AG for biliary tract infection?
for diabetics or others with signs of GN sepsis
what should i do with the abx if cholecystectomy for bilirary tract?
d/c abx within 24h unless infection outside of gallbladder
if there is complication with bilirary tract infxn, how long should be the therapy?
tx options for bilirary tract infection
- zosyn, timentin, unasyn
- 3rd cephalo + metro
- aztreonam + metro
- cipro + metro
tx for life threatening bilirary tract infxn
- mero, imi, dori
- (all carbapenems cept erta)
pathophys of peritonitis?
- bacterial contamination
- release of humoral inflamm mediators
- recruit macrophage, PML
spontaneous bacterial peritonitis is also known as ___.
primary peritonitis is freq in those with ___.
- metastiatic malignancy
does primary peritonitis have intra-abd abnormality?
pathophys of primary peritonitis?
- bacterial translocation
- bacterial overgrowth
- dec motility
- sturctural damage
- dec host defense mechanism
do you need to cover for GN in primary peritonitis?
do you need to cover for GP in primary peritonitis?
- GM cocci
- strep, pneumo, entero
do you need to cover anaerobe in primary peritonitis?
which two abx would you not need in primary peritonitis? why
- no AG: nephrotox
- no need to cover anaerobes so exclude these abx
tx for primary peritonitis?
- cefotaxime, ceftriaxone (3rd gen)
- zosyn, timentin, unasyn
- no AG or anaerobe abx needed
when will abx respond for primary peritonitis?
within 72 h
how long should be the tx for primary peritonitis?
5d - 2wk
pathophys of secondary peritonitis?
- fecal contamination of peritoneal cavity
- perforation of GI tract
- intraperitoneal or visceral absecess
how to treat secondary peritonitis?
what bacteria to target for secondary peritonitis?
- aerobic GN bacilli (e.coli, kleb, proteus, enterobacter)
- anaerobes (b.fragilis) (unlike primary perito)
tx for mild-mod secondary peritonitis?
- zosyn, unasyn, timentin
- cipro, levo, moxi + metro
- cefepime + metro
tx for severe secondary peritonitis?
all carba except erta
S&S of tertiary perito?
- multiorgan dysfunct
CAPD stands for...
continuous ambulatory peritoneal dialysis
microbiology of CAPD?
- coag negative staph
- GN bacilli - e.coli
- s. epi, s. aur, streptococc, diphteroids
tx for CAPD?
vanco + ceftazidime or gentamycin IV
what to do if no response for abx for CAPD in 48 h?
is gram stain recommended for intra-abd? when?
- not routinely recomm; no need if community acquired
- use if clinically toxic, immunocompromised, significant resistance, health care infxn (yeast)
bugs for community acquired mild-mod?
- enteric GN aerobe bacilli
- enteric GP streptococci
- anaerobes (distal small bowel, appendiceal, colon-derived)
tx for comm acq mild-mod intra abd?
- for pseudo: zosyn; levo or cipro + metro
- cefazolin, cefuroxime, or ceftriaxone + metro
- GP, GN: erta, tige
- anaerobe: cefoxitin, erta
to cover anaerobe in comm acq mild-mod IAI, what cephamycin to use?
- (resistance with cefotetan)
erta covers what bacteria?
GN, GP, anaerobe
which FQ has the best anaerobic coverage? can you use this solely for anaerobe?
- cannot rely alone, need flagyl
does tige cover anaerobe?
does tige cover pseudo?
which abx is great for intra-abd surgery? why? any SE?
- goes to liver
- great if renal issue or sepsis
- SE of NV (common in young b/c serotonin release)
bugs for high risk comm acq IAI?
tx for comm acq high risk IAI?
- pseudo: all carba except erta; zosyn; ceftazidime or cefepime + metro
- cipro or levo + metro
bugs for health care assoc IAI?
- GN aerobic bacilli
drugs for health care assoc IAI?
- all carba cept erta
- ceftazidime or cefepime + metro
- acinetobacter: aminoglycosides, colistin
when do you use antifungal tx for IAI?
- high risk comm acq
- health care assoc
what to give if candida IAI? what if resistance?
- if resistant, critical pt or immunocompromised: echinocandin (fungin)
when to give anti-enterococcal tx? what is the tx?
- health care assoc: previous abx, immunocompromised, valvular heart disease
- target e. faecalis
- ampicillin, zosyn, vanco, lin, dapto
when to initiate anti-MRSA tx?
what is the tx?
- health care assoc: known to be colonized, prior tx fail, significant abx exposure
how long should IAI abx tx be?
limit to 4-7d
regimen and duration of therapy for surgical?
- postpone to give 24h of ppx
- bactrim or cipro
what are oral therapy for IAI to complete the abx course?
- moxi, cipro or levo + metro
- cephalo + metro
cholangitis has ___ left shift and ___ jaundice than cholecystitis.
- more left shift
- less jaundice
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