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Guideline Summary
Guideline Title
Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America.
Bibliographic Source(s)
Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, O'Neill PJ, Chow AW, Dellinger EP, Eachempati SR, Gorbach S, Hilfiker M, May AK, Nathens AB, Sawyer RG, Bartlett JG. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010 Jan 15;50(2):133-64. [189 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Solomkin JS, Mazuski JE, Baron EJ, Sawyer RG, Nathens AB, DiPiro JT, Buchman T, Dellinger EP, Jernigan J, Gorbach S, Chow AW, Bartlett J. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis 2003 Oct 15;37(8):997-1005. [71 references]

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • September 27, 2013 – Tygacil (tigecycline) External Web Site Policy: The U.S. Food and Drug Administration (FDA) notified health professionals and their medical care organizations of a new Boxed Warning describing an increased risk of death when intravenous Tygacil is used for FDA-approved uses as well as for non-approved uses. These changes to the Tygacil Prescribing Information are based on an additional analysis that was conducted for FDA-approved uses after FDA issuing a Drug Safety Communication about this safety concern in September 2010.
  • August 15, 2013 – Fluoroquinolone Antibacterial Drugs External Web Site Policy: The U.S. Food and Drug Administration (FDA) has required the drug labels and Medication Guides for all fluoroquinolone antibacterial drugs be updated to better describe the serious side effect of peripheral neuropathy. This serious nerve damage potentially caused by fluoroquinolones may occur soon after these drugs are taken and may be permanent.

Scope

Disease/Condition(s)

Complicated intra-abdominal infections including peritonitis, cholecystitis, cholangitis, and acute appendicitis

Note: Complicated intra-abdominal infection extends beyond the hollow viscus of origin into the peritoneal space and is associated with either abscess formation or peritonitis. These guidelines do not include management of nonperforated primary enteritis and/or colitis or perforations due to diseases that are rare in North America.

Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Critical Care
Emergency Medicine
Infectious Diseases
Internal Medicine
Pediatrics
Pharmacology
Radiology
Surgery
Intended Users
Clinical Laboratory Personnel
Pharmacists
Physicians
Guideline Objective(s)
  • To provide a framework for managing complicated intra-abdominal infection involving supportive intensive care, diagnostic imaging, minimally invasive intervention, and antimicrobial therapy
  • To update and replace guidelines previously published in 2002 and 2003 for managing patients with intra-abdominal infection
Target Population

Pediatric and adult patients with complicated intra-abdominal infections or who may be at risk for them

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Initial diagnostic evaluation
    • Medical history
    • Physical examination
    • Laboratory studies
  2. Microbial evaluation
    • Blood cultures
    • Gram stain
    • Cultures from the site of infection
    • Susceptibility testing
  3. Computed tomography (CT) or ultrasonography imaging

Treatment/Management

  1. Fluid resuscitation
  2. Timing of antimicrobial therapy initiation
  3. Use of appropriate source control procedures (e.g., drainage of abscesses, diversion, resection)
  4. Antimicrobial therapy in adults
    • Regimens for community-acquired infection of mild-to-moderate severity
    • Regimens for high-risk community-acquired infection
    • Regimens for health care–associated infection, including antifungal, anti-enterococcal, and anti–methicillin-resistant Staphylococcus aureus (MRSA) therapy
    • Regimens for acute cholecystitis and cholangitis
  5. Antimicrobial therapy in pediatric infection
    • Selection of specific antimicrobial therapy for patients with complicated infection
    • Therapy of necrotizing enterocolitis in neonates
  6. Pharmacokinetics considerations (appropriate dosing)
  7. Use of microbiological culture results to guide antimicrobial therapy
  8. Duration of therapy for complicated infections in adults
  9. Oral or outpatient intravenous antimicrobial therapy in children and adults
  10. Management of suspected treatment failure
  11. Development of local pathways for diagnosis and management of acute appendicitis
Major Outcomes Considered
  • Sensitivity and specificity of diagnostic tests
  • Outcomes associated with complicated intra-abdominal infections (e.g., patient mortality, failure rates, health care costs)
  • Efficacy of anti-infective therapy, measured by clinical signs, temperature, white blood cell count, and gastrointestinal function
  • Development of clinical and microbiological resistance

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Literature Review and Analysis

The Panel reviewed studies on the site of origin of intra-abdominal infections, their microbiology, the laboratory approach to diagnosis of infection, the selection and duration of antibiotic therapy, and use of ancillary therapeutic aids. The Panel further reviewed the initial diagnostic work-ups, resuscitations, timings of intervention, and source control elements for infection. Previous guidelines detail recommendations made in 2002 and 2003.

These guidelines are based on randomized clinical trials using antimicrobials for treatment of intra-abdominal infection published from 2002 through December 2008. The 2002 cut-off was used because relevant literature available through 2002 was used for the previous guidelines. The Medline database was searched using multiple strategies in which the names of specific antimicrobials or more general descriptors (i.e., cephalosporins) were paired with words and phrases indicating an intra-abdominal infection (i.e., peritonitis or appendicitis). Articles were also retrieved for review by searches for resuscitation, septic shock, computed tomography (CT) scan, imaging, appendicitis, diverticulitis, source control, wound closure, and drainage. The Panel members contributed reference lists in these areas. This search included studies that were in the Medline database as of December 2008. The Cochrane database was also searched for relevant trials.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of Evidence

Level I Evidence from at least 1 properly designed randomized, controlled trial
Level II Evidence from at least 1 well-designed clinical trial, without randomization; from cohort or
case-controlled analytic studies (preferably from >1 center); from multiple time series; or
from dramatic results of uncontrolled experiments
Level III Evidence from opinions of respected authorities, based on clinical experience, descriptive
studies, or reports of expert committees

Note: Adapted from Canadian Task Force on the Periodic Health Examination.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

In evaluating the information regarding the management of intra-abdominal infection, the Panel followed a process used to develop other Infectious Diseases Society of America (IDSA) guidelines. The published studies were first categorized according to study design and quality, and in turn, the recommendations developed from these studies were graded according to the strength of evidence behind them. The level of evidence and the strength of the recommendation for a particular point were defined as described in the "Rating Scheme for the Strength of the Evidence" and "Rating Scheme for the Strength of the Recommendations" fields.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Panel Composition

A panel of experts in infectious diseases, surgery, pharmacology, and microbiology was assembled by the Infectious Diseases Society of America (IDSA) and the Surgical Infection Society (SIS) to prepare these guidelines. The panelists had both clinical and laboratory experience.

Consensus Development on the Basis of Evidence

The Panel met on 4 occasions, 3 times via teleconference and once in person, to complete the guideline. The meetings were held to discuss the questions to be addressed, to make writing assignments, and to discuss recommendations. There was a large volume of e-mail comments, because drafts were regularly circulated electronically. All panel members participated in the preparation and review of the draft guideline.

Rating Scheme for the Strength of the Recommendations

Strength of Recommendation

Grade A Good evidence to support a recommendation for use
Grade B Moderate evidence to support a recommendation for use
Grade C Poor evidence to support a recommendation 

Note: Adapted from Canadian Task Force on the Periodic Health Examination.

Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

All panel members participated in the preparation and review of the draft guideline. Feedback from external peer reviewers was obtained. The guideline was reviewed and endorsed by the Pediatric Infectious Diseases Society, the American Society for Microbiology, the American Society of Health-System Pharmacists, and the Society of Infectious Disease Pharmacists. The guideline was also reviewed and approved by the Infectious Diseases Society of America (IDSA) Standards and Practice Guidelines Committee, the IDSA Board of Directors, the Surgical Infection Society (SIS) Therapeutics and Guidelines Committee, and the SIS Executive Council prior to dissemination.

Recommendations

Major Recommendations

Definitions for the quality of the evidence (I–III) and strength of recommendation (A–C) are given at the end of the "Major Recommendations" field.

What Are the Appropriate Procedures for Initial Evaluation of Patients with Suspected Intra-abdominal Infection?

  1. Routine history, physical examination, and laboratory studies will identify most patients with suspected intra-abdominal infection for whom further evaluation and management is warranted (A-II).
  2. For selected patients with unreliable physical examination findings, such as those with an obtunded mental status or spinal cord injury or those immunosuppressed by disease or therapy, intra-abdominal infection should be considered if the patient presents with evidence of infection from an undetermined source (B-III).
  3. Further diagnostic imaging is unnecessary in patients with obvious signs of diffuse peritonitis and in whom immediate surgical intervention is to be performed (B-III).
  4. In adult patients not undergoing immediate laparotomy, computed tomography (CT) scan is the imaging modality of choice to determine the presence of an intra-abdominal infection and its source (A-II).

When Should Fluid Resuscitation Be Started for Patients with Suspected Intra-abdominal Infection?

  1. Patients should undergo rapid restoration of intravascular volume and additional measures as needed to promote physiological stability (A-II).
  2. For patients with septic shock, such resuscitation should begin immediately when hypotension is identified (A-II).
  3. For patients without evidence of volume depletion, intravenous fluid therapy should begin when the diagnosis of intra-abdominal infection is first suspected (B-III).

When Should Antimicrobial Therapy Be Initiated for Patients with Suspected or Confirmed Intra-abdominal Infection?

  1. Antimicrobial therapy should be initiated once a patient receives a diagnosis of an intra-abdominal infection or once such an infection is considered likely. For patients with septic shock, antibiotics should be administered as soon as possible (A-III).
  2. For patients without septic shock, antimicrobial therapy should be started in the emergency department (B-III).
  3. Satisfactory antimicrobial drug levels should be maintained during a source control intervention, which may necessitate additional administration of antimicrobials just before initiation of the procedure (A-I).

What Are the Proper Procedures for Obtaining Adequate Source Control?

  1. An appropriate source control procedure to drain infected foci, control ongoing peritoneal contamination by diversion or resection, and restore anatomic and physiological function to the extent feasible is recommended for nearly all patients with intra-abdominal infection (B-II).
  2. Patients with diffuse peritonitis should undergo an emergency surgical procedure as soon as is possible, even if ongoing measures to restore physiologic stability need to be continued during the procedure (B-II)
  3. Where feasible, percutaneous drainage of abscesses and other well-localized fluid collections is preferable to surgical drainage (B-II).
  4. For hemodynamically stable patients without evidence of acute organ failure, an urgent approach should be taken. Intervention may be delayed for as long as 24 hours if appropriate antimicrobial therapy is given and careful clinical monitoring is provided (B-II).
  5. In patients with severe peritonitis, mandatory or scheduled relaparotomy is not recommended in the absence of intestinal discontinuity, abdominal fascial loss that prevents abdominal wall closure, or intra-abdominal hypertension (A-II).
  6. Highly selected patients with minimal physiological derangement and a well-circumscribed focus of infection, such as a periappendiceal or pericolonic phlegmon, may be treated with antimicrobial therapy alone without a source control procedure, provided that very close clinical follow-up is possible (B-II)

When and How Should Microbiological Specimens Be Obtained and Processed?

  1. Blood cultures do not provide additional clinically relevant information for patients with community-acquired intra-abdominal infection and are therefore not routinely recommended for such patients (B-III).
  2. If a patient appears clinically toxic or is immunocompromised, knowledge of bacteremia may be helpful in determining duration of antimicrobial therapy (B-III).
  3. For community-acquired infections, there is no proven value in obtaining a routine Gram stain of the infected material (C-III).
  4. For health care–associated infections, Gram stains may help define the presence of yeast (C-III).
  5. Routine aerobic and anaerobic cultures from lower-risk patients with community-acquired infection are considered optional in the individual patient but may be of value in detecting epidemiological changes in the resistance patterns of pathogens associated with community-acquired intra-abdominal infection and in guiding follow-up oral therapy (B-II).
  6. If there is significant resistance (i.e., resistance in 10%–20% of isolates) of a common community isolate (e.g., E. coli) to an antimicrobial regimen in widespread local use, routine culture and susceptibility studies should be obtained for perforated appendicitis and other community-acquired intra-abdominal infections (B-III).
  7. Anaerobic cultures are not necessary for patients with community-acquired intra-abdominal infection if empiric antimicrobial therapy active against common anaerobic pathogens is provided (B-III).
  8. For higher-risk patients, cultures from the site of infection should be routinely obtained, particularly in patients with prior antibiotic exposure, who are more likely than other patients to harbor resistant pathogens (A-II).
  9. The specimen collected from the intra-abdominal focus of infection should be representative of the material associated with the clinical infection (B-III).
  10. Cultures should be performed from 1 specimen, provided it is of sufficient volume (at least 1 mL of fluid or tissue, preferably more) and is transported to the laboratory in an appropriate transport system. For optimal recovery of aerobic bacteria, 1–10 mL of fluid should be inoculated directly into an aerobic blood culture bottle. In addition, 0.5 mL of fluid should be sent to the laboratory for Gram stain and, if indicated, fungal cultures. If anaerobic cultures are requested, at least 0.5 mL of fluid or 0.5 g of tissue should be transported in an anaerobic transport tube. Alternately, for recovery of anaerobic bacteria, 1–10 mL of fluid can be inoculated directly into an anaerobic blood culture bottle (A-I).
  11. Susceptibility testing for Pseudomonas, Proteus, Acinetobacter, Staphylococcus aureus, and predominant Enterobacteriaceae, as determined by moderate-to-heavy growth, should be performed, because these species are more likely than others to yield resistant organisms (A-III).

What Are Appropriate Antimicrobial Regimens for Patients with Community-acquired Intra-abdominal Infection of Mild-to-moderate Severity?

  1. Antibiotics used for empiric treatment of community-acquired intra-abdominal infection should be active against enteric gram-negative aerobic and facultative bacilli and enteric gram-positive streptococci (A-I).
  2. Coverage for obligate anaerobic bacilli should be provided for distal small bowel, appendiceal, and colon-derived infection and for more proximal gastrointestinal perforations in the presence of obstruction or paralytic ileus (A-I).
  3. For adult patients with mild-to-moderate community-acquired infection, the use of ticarcillin-clavulanate, cefoxitin,  ertapenem, moxifloxacin, or tigecycline as single-agent therapy or combinations of metronidazole with cefazolin, cefuroxime, ceftriaxone, cefotaxime, levofloxacin, or ciprofloxacin are preferable to regimens with substantial anti-Pseudomonal activity (see Table 2 in the original guideline document) (A-I).
  4. Ampicillin-sulbactam is not recommended for use because of high rates of resistance to this agent among community-acquired E. coli (B-II).
  5. Cefotetan and clindamycin are not recommended for use because of increasing prevalence of resistance to these agents among the Bacteroides fragilis group (B-II).
  6. Because of the availability of less toxic agents demonstrated to be at least equally effective, aminoglycosides are not recommended for routine use in adults with community-acquired intra-abdominal infection (B-II).
  7. Empiric coverage of Enterococcus is not necessary in patients with community-acquired intra-abdominal infection (A-I).
  8. Empiric antifungal therapy for Candida is not recommended for adult and pediatric patients with community-acquired intra-abdominal infection (B-II).
  9. The use of agents listed as appropriate for higher-severity community-acquired infection and health care–associated infection is not recommended for patients with mild-to-moderate community-acquired infection, because such regimens may carry a greater risk of toxicity and facilitate acquisition of more resistant organisms (B-II).
  10. For those patients with intra-abdominal infection of mild-to-moderate severity, including acute diverticulitis and various forms of appendicitis, who will not undergo a source control procedure, regimens listed for treatment of mild-to-moderate–severity infection are recommended, with a possibility of early oral therapy (B-III).

What Are Appropriate Antimicrobial Regimens for Patients with Community-acquired Intra-abdominal Infection of High Severity?

  1. The empiric use of antimicrobial regimens with broad-spectrum activity against gram-negative organisms, including meropenem, imipenem-cilastatin, doripenem, piperacillin-tazobactam, ciprofloxacin or levofloxacin in combination with metronidazole, or ceftazidime or cefepime in combination with metronidazole, is recommended for patients with high-severity community-acquired intra-abdominal infection, as defined by Acute Physiology and Chronic Health Evaluation (APACHE) II scores >15 or other variables listed in Table 1 in the original guideline document (see Table 2 in the original guideline document) (A-I).
  2. Quinolone-resistant E. coli have become common in some communities, and quinolones should not be used unless hospital surveys indicate >90% susceptibility of E. coli to quinolones (A-II).
  3. Aztreonam plus metronidazole is an alternative, but addition of an agent effective against gram-positive cocci is recommended (B-III).
  4. In adults, routine use of an aminoglycoside or another second agent effective against gram-negative facultative and aerobic bacilli is not recommended in the absence of evidence that the patient is likely to harbor resistant organisms that require such therapy (A-I).
  5. Empiric use of agents effective against enterococci is recommended (B-II).
  6. Use of agents effective against methicillin-resistant Staphylococcus aureus (MRSA) or yeast is not recommended in the absence of evidence of infection due to such organisms (B-III).
  7. In these high-risk patients, antimicrobial regimens should be adjusted according to culture and susceptibility reports to ensure activity against the predominant pathogens isolated in culture (A-III).

What Antimicrobial Regimens Should Be Used in Patients with Health Care–associated Intra-abdominal Infection, Particularly with Regard to Candida, Enterococcus, and MRSA?

  1. Empiric antibiotic therapy for health care–associated intra-abdominal infection should be driven by local microbiologic results (A-II).
  2. To achieve empiric coverage of likely pathogens, multidrug regimens that include agents with expanded spectra of activity against gram-negative aerobic and facultative bacilli may be needed. These agents include meropenem, imipenem-cilastatin, doripenem, piperacillin-tazobactam, or ceftazidime or cefepime in combination with metronidazole. Aminoglycosides or colistin may be required (see Table 3 in the original guideline document) (B-III).
  3. Broad-spectrum antimicrobial therapy should be tailored when culture and susceptibility reports become available, to reduce the number and spectra of administered agents (B-III).

Antifungal Therapy

  1. Antifungal therapy for patients with severe community acquired or health care–associated infection is recommended if Candida is grown from intra-abdominal cultures (B-II).
  2. Fluconazole is an appropriate choice for treatment if C. albicans is isolated (B-II).
  3. For fluconazole-resistant Candida species, therapy with an echinocandin (caspofungin, micafungin, or anidulafungin) is appropriate (B-III).
  4. For the critically ill patient, initial therapy with an echinocandin instead of a triazole is recommended (B-III).
  5. Because of toxicity, amphotericin B is not recommended as initial therapy (B-II).
  6. In neonates, empiric antifungal therapy should be started if Candida is suspected. If C. albicans is isolated, fluconazole is an appropriate choice (B-II)

Anti-Enterococcal Therapy

  1. Antimicrobial therapy for enterococci should be given when enterococci are recovered from patients with health care–associated infection (B-III).
  2. Empiric anti-enterococcal therapy is recommended for patients with health care–associated intra-abdominal infection, particularly those with postoperative infection, those who have previously received cephalosporins or other antimicrobial agents selecting for Enterococcus species, immunocompromised patients, and those with valvular heart disease or prosthetic intravascular materials (B-II).
  3. Initial empiric anti-enterococcal therapy should be directed against Enterococcus faecalis. Antibiotics that can potentially be used against this organism, on the basis of susceptibility testing of the individual isolate, include ampicillin, piperacillin-tazobactam, and vancomycin (B-III).
  4. Empiric therapy directed against vancomycin-resistant Enterococcus faecium is not recommended unless the patient is at very high risk for an infection due to this organism, such as a liver transplant recipient with an intra-abdominal infection originating in the hepatobiliary tree or a patient known to be colonized with vancomycin-resistant E. faecium (B-III).

Anti-MRSA Therapy

  1. Empiric antimicrobial coverage directed against MRSA should be provided to patients with health care–associated intra-abdominal infection who are known to be colonized with the organism or who are at risk of having an infection due to this organism because of prior treatment failure and significant antibiotic exposure (B-II).
  2. Vancomycin is recommended for treatment of suspected or proven intra-abdominal infection due to MRSA (A-III).

What Are Appropriate Diagnostic and Antimicrobial Therapeutic Strategies for Acute Cholecystitis and Cholangitis?

  1. Ultrasonography is the first imaging technique used for suspected acute cholecystitis or cholangitis (A-I).
  2. Patients with suspected infection and either acute cholecystitis or cholangitis should receive antimicrobial therapy, as recommended in Table 4 in the original guideline document, although anaerobic therapy is not indicated unless a biliary-enteric anastamosis is present (B-II).
  3. Patients undergoing cholecystectomy for acute cholecystitis should have antimicrobial therapy discontinued within 24 hours unless there is evidence of infection outside the wall of the gallbladder (B-II).
  4. For community-acquired biliary infection, antimicrobial activity against enterococci is not required, because the pathogenicity of enterococci has not been demonstrated. For selected immunosuppressed patients, particularly those with hepatic transplantation, enterococcal infection may be significant and require treatment (B-III).

What Are Appropriate Antimicrobial Regimens for Pediatric Patients with Community-acquired Intra-abdominal Infection?

  1. Routine use of broad-spectrum agents is not indicated for all children with fever and abdominal pain for whom there is a low suspicion of complicated appendicitis or other acute intra-abdominal infection (B-III).
  2. Selection of specific antimicrobial therapy for pediatric patients with complicated intra-abdominal infection should be based on considerations of the origin of infection (community vs. health care), severity of illness, and safety of the antimicrobial agents in specific pediatric age groups (A-II).
  3. Acceptable broad-spectrum antimicrobial regimens for pediatric patients with complicated intra-abdominal infection include an aminoglycoside-based regimen, a carbapenem (imipenem, meropenem, or ertapenem), a beta-lactam/beta-lactamase–inhibitor combination (piperacillin-tazobactam or ticarcillin-clavulanate), or an advanced-generation cephalosporin (cefotaxime, ceftriaxone, ceftazidime, or cefepime) with metronidazole (see Tables 2 and 5 in the original guideline document) (B-II).
  4. For children with severe reactions to beta-lactam antibiotics, ciprofloxacin plus metronidazole or an aminoglycoside-based regimen are recommended (B-III).
  5. Necrotizing enterocolitis in neonates is managed with fluid resuscitation, intravenous broad-spectrum antibiotics (potentially including antifungal agents), and bowel decompression. Urgent or emergent operative intervention, consisting of either laparotomy or percutaneous drainage, should be performed when there is evidence of bowel perforation. Intraoperative Gram stains and cultures should be obtained (B-III).
  6. Broad-spectrum antibiotics that may be useful in neonates with this condition include ampicillin, gentamicin, and metronidazole; ampicillin, cefotaxime, and metronidazole; or meropenem. Vancomycin may be used instead of ampicillin for suspected MRSA or ampicillin-resistant enterococcal infection. Fluconazole or amphotericin B should be used if the Gram stain or cultures of specimens obtained at operation are consistent with a fungal infection (B-II).

What Constitutes Appropriate Antibiotic Dosing?

  1. Empiric therapy of patients with complicated intra-abdominal infection requires the use of antibiotics at optimal doses to ensure maximum efficacy and minimal toxicity and to reduce antimicrobial resistance (see Tables 5 and 6 in the original guideline document) (B-II).
  2. Individualized daily administration of aminoglycosides according to lean body mass and estimated extracellular fluid volume is preferred for patients receiving these agents for intra-abdominal infection (B-III).

How Should Microbiological Culture Results Be Used to Adjust Antimicrobial Therapy?

  1. Lower-risk patients with community-acquired intra-abdominal infection do not require alteration of therapy if a satisfactory clinical response to source control and initial therapy occurs, even if unsuspected and untreated pathogens are later reported (B-III).
  2. If resistant bacteria were identified at the time of initial intervention and there are persistent signs of infection, pathogen-directed therapy is recommended for patients with lower-severity disease (B-III).
  3. Use of culture and susceptibility results to determine antimicrobial therapy in high-severity community-acquired or health care–associated infection should be based on pathogenic potential and density of identified organisms (B-III).
  4. Microbes recovered from blood cultures should be assumed to be significant if they have established pathogenic potential or are present in ≥2 blood cultures (A-I) or if they are recovered in moderate or heavy concentrations from samples obtained from drainage (B-II).

What Is the Appropriate Duration of Therapy for Patients with Complicated Intra-abdominal Infection?

  1. Antimicrobial therapy of established infection should be limited to 4 to 7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome (B-III).
  2. For acute stomach and proximal jejunum perforations, in the absence of acid-reducing therapy or malignancy and when source control is achieved within 24 hours, prophylactic anti-infective therapy directed at aerobic gram-positive cocci for 24 hours is adequate (B-II).
  3. In the presence of delayed operation for acute stomach and proximal jejunum perforations, the presence of gastric malignancy or the presence of therapy reducing gastric acidity, antimicrobial therapy to cover mixed flora (e.g., as seen in complicated colonic infection) should be provided (B-III).
  4. Bowel injuries attributable to penetrating, blunt, or iatrogenic trauma that are repaired within 12 hours and any other intraoperative contamination of the operative field by enteric contents should be treated with antibiotics for ≤24 hours (A-I).
  5. Acute appendicitis without evidence of perforation, abscess, or local peritonitis requires only prophylactic administration of narrow spectrum regimens active against aerobic and facultative and obligate anaerobes; treatment should be discontinued within 24 hours (A-I).
  6. The administration of prophylactic antibiotics to patients with severe necrotizing pancreatitis prior to the diagnosis of infection is not recommended (A-I).

What Patients Should Be Considered for Oral or Outpatient Antimicrobial Therapy and What Regimens Should Be Used?

  1. For children and adults whose signs and symptoms of infection are resolved, no further antibiotic therapy is required (B-III).
  2. For adults recovering from intra-abdominal infection, completion of the antimicrobial course with oral forms of moxifloxacin, ciprofloxacin plus metronidazole, levofloxacin plus metronidazole, an oral cephalosporin with metronidazole, or amoxicillin-clavulanic acid (B-II) is acceptable in patients able to tolerate an oral diet and in patients in whom susceptibility studies do not demonstrate resistance (B-II).
  3. If culture and susceptibility testing identify organisms that are only susceptible to intravenous therapy, such therapy may be administered outside of the hospital (B-III).
  4. For children, outpatient parenteral antibiotic management may be considered when subsequent drainage procedures are not likely to be required but symptoms of ongoing intra-abdominal inflammation persist in the context of decreasing fever, controlled pain, ability to tolerate oral fluids, and ability to ambulate (B-II).
  5. For oral step-down therapy in children, intra-abdominal cultures at the time of the drainage procedure are recommended to allow for the use of the narrowest-spectrum, best-tolerated, and safest oral therapy. A second- or third-generation cephalosporin in combination with metronidazole, or amoxicillin-clavulanate, may be options if the isolated organisms are susceptible to these agents. Fluoroquinolones, such as ciprofloxacin or levofloxacin, may be used to treat susceptible Pseudomonas, Enterobacter, Serratia, and Citrobacter species (B-III). If ciprofloxacin or levofloxacin is used, metronidazole should be added.
  6. Drug susceptibility results of isolated gram-negative aerobic and facultative organisms, if available, should be used as a guide to agent selection in children and adults (B-III).
  7. Because many of the patients who are managed without a primary source control procedure may be treated in the outpatient setting, the oral regimens recommended (see recommendations 83 and 86 above) can also be used as either primary therapy or step-down therapy following initial intravenous antimicrobial therapy (B-III).

How Should Suspected Treatment Failure Be Managed?

  1. In patients who have persistent or recurrent clinical evidence of intra-abdominal infection after 4 to 7 days of therapy, appropriate diagnostic investigation should be undertaken. This should include computed tomography (CT) or ultrasound imaging. Antimicrobial therapy effective against the organisms initially identified should be continued (A-III).
  2. Extra-abdominal sources of infection and noninfectious inflammatory conditions should also be investigated if the patient is not experiencing a satisfactory clinical response to a microbiologically adequate initial empiric antimicrobial regimen (A-II).
  3. For patients who do not respond initially and for whom a focus of infection remains, both aerobic and anaerobic cultures should be performed from 1 specimen provided it is of sufficient volume (at least 1.0 mL of fluid or tissue) and is transported to the laboratory in an anaerobic transport system (C-III). Inoculation of 1–10 mL of fluid directly into an anaerobic blood culture broth bottle may improve yield.

What Are the Key Elements That Should Be Considered in Developing a Local Appendicitis Pathway?

  1. Local hospitals should establish clinical pathways to standardize diagnosis, in-hospital management, discharge, and outpatient management (B-II).
  2. Pathways should be designed by collaborating clinicians involved in the care of these patients, including but not limited to surgeons, infectious diseases specialists, primary care practitioners, emergency medicine physicians, radiologists, nursing providers, and pharmacists, and should reflect local resources and local standards of care (B-II).
  3. Although no clinical findings are unequivocal in identifying patients with appendicitis, a constellation of findings, including characteristic abdominal pain, localized abdominal tenderness, and laboratory evidence of acute inflammation, will generally identify most patients with suspected appendicitis (A-II).
  4. Helical CT of the abdomen and pelvis with intravenous, but not oral or rectal, contrast is the recommended imaging procedure for patients with suspected appendicitis (B-II).
  5. All female patients should undergo diagnostic imaging. Those of child-bearing potential should undergo pregnancy testing prior to imaging and, if in the first trimester of pregnancy, should undergo ultrasound or magnetic resonance instead of imaging ionizing radiation (B-II). If these studies do not define the pathology present, laparoscopy or limited CT scanning may be considered (B-III).
  6. Imaging should be performed for all children, particularly those aged <3 years, when the diagnosis of appendicitis is not certain. CT imaging is preferred, although to avoid use of ionizing radiation in children, ultrasound is a reasonable alternative (B-III).
  7. For patients with imaging study findings negative for suspected appendicitis, follow-up at 24 hours is recommended to ensure resolution of signs and symptoms, because of the low but measurable risk of false-negative results (B-III).
  8. For patients with suspected appendicitis that can neither be confirmed nor excluded by diagnostic imaging, careful follow-up is recommended (A-III).
  9. Patients may be hospitalized if the index of suspicion is high (A-III).
  10. Antimicrobial therapy should be administered to all patients who receive a diagnosis of appendicitis (A-II).
  11. Appropriate antimicrobial therapy includes agents effective against facultative and aerobic gram-negative organisms and anaerobic organisms, as detailed in Table 2 in the original guideline document for the treatment of patients with community-acquired intra-abdominal infection (A-I).
  12. For patients with suspected appendicitis whose diagnostic imaging studies are equivocal, antimicrobial therapy should be initiated along with appropriate pain medication and antipyretics, if indicated. For adults, antimicrobial therapy should be provided for a minimum of 3 days, until clinical symptoms and signs of infection resolve or a definitive diagnosis is made (B-III).
  13. Operative intervention for acute, nonperforated appendicitis may be performed as soon as is reasonably feasible. Surgery may be deferred for a short period of time as appropriate according to individual institutional circumstances (B-II).
  14. Both laparoscopic and open appendectomy are acceptable procedures, and use of either approach should be dictated by the surgeon's expertise in performing that particular procedure (A-I).
  15. Nonoperative management of selected patients with acute, nonperforated appendicitis can be considered if there is a marked improvement in the patient's condition prior to operation (B-II).
  16. Nonoperative management may also be considered as part of a specific approach for male patients, provided that the patient is admitted to the hospital for 48 hours and shows sustained improvement in clinical symptoms and signs within 24 hours while receiving antimicrobial therapy (A-II).
  17. Patients with perforated appendicitis should undergo urgent intervention to provide adequate source control (B-III).
  18. Patients with a well-circumscribed periappendiceal abscess can be managed with percutaneous drainage or operative drainage when necessary. Appendectomy is generally deferred in such patients (A-II).
  19. Selected patients who present several days after development of an inflammatory process and have a periappendiceal phlegmon or a small abscess not amenable to percutaneous drainage may delay or avoid a source control procedure to avert a potentially more morbid procedure than simple appendectomy. Such patients are treated with antimicrobial therapy and careful inpatient follow-up, in a manner analogous to patients with acute diverticulitis (B-II).
  20. The use of interval appendectomy after percutaneous drainage or nonoperative management of perforated appendicitis is controversial and may not be necessary (A-II).

Definitions:

Assessment Type of Evidence
Strength of Recommendation
Grade A Good evidence to support a recommendation for use
Grade B Moderate evidence to support a recommendation for use
Grade C Poor evidence to support a recommendation 
Quality of Evidence
Level I Evidence from at least 1 properly designed randomized, controlled trial
Level II Evidence from at least 1 well-designed clinical trial, without randomization; from cohort or
case-controlled analytic studies (preferably from >1 center); from multiple time series; or
from dramatic results of uncontrolled experiments
Level III Evidence from opinions of respected authorities, based on clinical experience, descriptive
studies, or reports of expert committees

Note: Adapted from Canadian Task Force on the Periodic Health Examination.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate diagnosis and management of complicated intra-abdominal infection in adults and children
  • Timely and effective anti-infective therapy
Potential Harms
  • Side effects and toxicity of antimicrobial therapy
  • Development of antimicrobial resistance

Contraindications

Contraindications

Therapy for pediatric patients with complicated intra-abdominal infection is constrained by safety concerns. Tetracyclines, such as tigecycline, are contraindicated for infections in children aged <8 years. Parenteral fluoroquinolones are not routinely recommended for treatment of infection in situations for which an equally effective alternative exists.

Qualifying Statements

Qualifying Statements

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, O'Neill PJ, Chow AW, Dellinger EP, Eachempati SR, Gorbach S, Hilfiker M, May AK, Nathens AB, Sawyer RG, Bartlett JG. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010 Jan 15;50(2):133-64. [189 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2003 (revised 2010 Jan 15)
Guideline Developer(s)
Infectious Diseases Society of America - Medical Specialty Society
Surgical Infection Society - Professional Association
Source(s) of Funding

Infectious Diseases Society of America (IDSA) and Surgical Infection Society

Guideline Committee

Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America

Composition of Group That Authored the Guideline

Panel Members: Joseph S. Solomkin, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio; John E. Mazurski, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; John S. Bradley, Department of Pediatric Infectious Diseases, Rady Children's Hospital of San Diego, San Diego; Keith A. Rodvold, Departments of Pharmacy Practice and Medicine, University of Illinois at Chicago, Chicago; Ellie J.C. Goldstein, R. M. Alden Research Laboratory, David Geffen School of Medicine at UCLA, Los Angeles; Ellen J. Baron, Department of Pathology, Stanford University School of Medicine, Palo Alto, California; Patrick J. O'Neill, Department of Surgery, The Trauma Center at Maricopa Medical Center, Phoenix, Arizona; Anthony W. Chow, Department of Medicine, University of British Columbia, Vancouver, British Columbia; E. Patchen Dellinger, Department of Surgery, University of Washington, Seattle; Soumitra R. Eachempati, Department of Surgery, Cornell Medical Center, New York, New York; Sherwood Gorbach, Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts; Mary Hilfiker, Department of Surgery, Rady Children's Hospital of San Diego, San Diego; Addison K. May, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Avery B. Nathens, St. Michael's Hospital, Toronto, Ontario, Canada; Robert G. Sawyer, Department of Surgery, University of Virginia, Charlottesville; John G. Bartlett, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Financial Disclosures/Conflicts of Interest

All members of the Expert Panel complied with the Infectious Diseases Society of America (IDSA) policy regarding conflicts of interest, which requires disclosure of any financial or other interest that might be construed as constituting an actual, potential, or apparent conflict. Members of the Expert Panel were provided a conflict of interest disclosure statement from the IDSA and were asked to identify ties to companies developing products that might be affected by promulgation of the guideline. Information was requested regarding employment, consultancies, stock ownership, honoraria, research funding, expert testimony, and membership on company advisory committees. The Panel made decisions on a case-by-case basis as to whether an individual's role should be limited as a result of a conflict. No limiting conflicts were identified.

Potential Conflicts of Interest

J.S.S. has received honoraria for lectures in China from Merck; financial support as consultant and principal investigator of a clinical research project in China and honoraria for lectures from Bayer; financial support as consultant, advisory board member, and lecturer from Johnson & Johnson; research support for a project on the interaction of PVL and neutrophils from Pfizer; financial support as consultant, advisory board member, and lecturer from Shering-Plough; and financial support as advisory board member from Optimer. J.E.M. received research support form Artisan Pharmaceuticals, Eli Lilly, Ortho Biotech, Peninsula Pharmaceuticals, Pfizer Pharmaceuticals, and Theravance and has served as a paid consultant, advisory board member, or speaker for Eli Lilly, Merck, Ortho-McNeil Pharmaceuticals, Pfizer Pharmaceuticals, Schering-Plough, and Wyeth Pharmaceuticals. J.G.B. has served on the advisory boards of Abbott Laboratories, Bristol, Pfizer Pharmaceuticals, Tibotee, GlaxoSmithKline and served on the policy board of Johnson & Johnson. J.S.B. has served as a consultant to and received research funding from AstraZeneca, Wyeth Pharmaceuticals, and Johnson & Johnson. A.W.C. served as a speaker for Wyeth Pharmaceuticals and Bayer, is a member of the guideline committee of the Association of Medical Microbiology and Infectious Diseases Canada, and is coauthor of the Canadian Practice Guidelines for Surgical Intra-abdominal Infections. A.B.N. has served as a speaker for Bayer, Schering-Plough, and Wyeth Pharmaceuticals. K.A.R. received research grants and contracts from Sanofi-Aventis and Roche Laboratories; has served as a consultant to Johnson & Johnson, Ortho-McNeil Pharmaceuticals, and GlaxoSmithKline; serves on the speakers bureau or advisory board of Abbott Laboratories, Astellas Pharmaceuticals, Astra-Zeneca Pharmaceuticals, Daiichi Pharmaceuticals, Ortho-McNeil Pharmaceuticals, Pfizer Pharmaceuticals, Schering-Plough, Targanta, Theravance, and Wyeth Pharmaceuticals; and is a shareholder of Pfizer Pharmaceuticals. R.G.S. has served as a consultant to Pfizer Pharmaceuticals, Merck, Wyeth Pharmaceuticals, and Schering-Plough. E.J.B. has received honoraria or served on advisory panels for Ortho-McNeil, GlaxoSmithKline, Aventis, Cepheid, Becton-Dickinson, bioMerieux, Cubist, Wyeth-Ayerst, Johnson & Johnson, Astra-Zeneca, and Oxonica; received research support from Roche Molecular Diagnostics; and owns shares of Cepheid and Merck. E.J.C.G. has served on advisory boards for Merck, Schering-Plough Pharmaceuticals, Optimer Pharmaceuticals, Theravance, Oculus Innovative Sciences, and Viropharma; has been on speakers bureaus for Ortho-McNiel, Merck, Schering-Plough, Theravance, and Bayer; and has received research grants from Merck, Schering-Plough, Cubist, Theravance, Optimer, Replidyne, Oculus Innovative Sciences, Pfizer, Astella, Cerexa, Impex pharmaceuticals, and Optimer Pharmaceuticals. E.P.D. has given lectures for honoraria and/or served on advisory boards for Bayer, Merck, Wyeth-Ayerst, AstraZeneca, Pfizer, Ortho-McNeil, Cubist, Vicuron, InterMune, Peninsula, Johnson & Johnson, Cepheid, Replidyne, Kimberley-Clark, Targanta, Schering-Plough, Enturia, Optimer, and BDGeneOhm. P.O. serves on the speakers' bureau for Pfizer Pharmaceuticals and is a member of the Surgery National Advisory Board. S.E. serves on advisory boards and the speakers’ bureau for Pfizer, Cubist, and Wyeth. All other authors: no conflicts.

Guideline Endorser(s)
American Society for Microbiology - Professional Association
American Society of Health-System Pharmacists - Professional Association
Pediatric Infectious Diseases Society - Medical Specialty Society
Society of Infectious Diseases Pharmacists - Professional Association
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Solomkin JS, Mazuski JE, Baron EJ, Sawyer RG, Nathens AB, DiPiro JT, Buchman T, Dellinger EP, Jernigan J, Gorbach S, Chow AW, Bartlett J. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis 2003 Oct 15;37(8):997-1005. [71 references]

Guideline Availability

Electronic copies: Available from the Infectious Disease Society of America (IDSA) Web site External Web Site Policy.

Print copies: Available from Infectious Diseases Society of America, 1300 Wilson Boulevard, Suite 300, Arlington, VA 22209.

Availability of Companion Documents

The following is available:

  • Kish MA. Guide to development of practice guidelines. Clin Infect Dis 2001 Mar 15;32(6):851-4. Available from the Clinical Infectious Diseases Journal Web site External Web Site Policy.

     

    Print copies: Available from Infectious Diseases Society of America, 1300 Wilson Boulevard, Suite 300, Arlington, VA 22209.

    Additionally, suggested performance measures are provided in the original guideline document External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on May 6, 2004. This summary was updated by ECRI on February 21, 2006 following the U.S. Food and Drug Administration (FDA) advisory on Tequin (gatifloxacin). This summary was updated by ECRI Institute on October 3, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium). This summary was updated by ECRI Institute on July 28, 2008 following the U.S. Food and Drug Administration advisory on fluoroquinolone antimicrobial drugs. This NGC summary was updated by ECRI Institute on March 31, 2010. This summary was updated by ECRI Institute on October 5, 2010 following the U.S. Food and Drug Administration (FDA) advisory on Tygacil (tigecycline). This summary was updated by ECRI Institute on September 10, 2012 following the U.S. Food and Drug Administration advisory on Cefepime. This summary was updated by ECRI Institute on October 24, 2013 following the U.S. Food and Drug Administration advisory on Tygacil (tigecycline). This summary was updated by ECRI Institute on October 25, 2013 following the U.S. Food and Drug Administration advisory on Fluoroquinolone Antibacterial Drugs.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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