Guidelines for the Treatment of Adults with Complicated Intra-abdominal Infections

Workup for Suspected Intra-abdominal Infection

Obtain history, perform a physical examination, and obtain appropriate laboratory studies
o
o
o

CMP, CBC
Blood Cultures (x 2 sets) prior to antimicrobial therapy
Culture and Gram stain (optional for low-risk patients) representative of source of infection (intraoperative or via drain). This is optional for uncomplicated, immunocompetent patients.

Consider CT scan if patient is not to undergo immediate surgical intervention.

Assess Volume Status of the patient, restore intra-vascular volume if necessary.

***Patients experiencing hemodynamic instability should be aggressively resuscitated in accordance with
accepted recommendations for sepsis and/or septic shock***

NOTE: Adequate source control is essential in treatment any infectious disease, however, certain instances will predict
clinical failure with source control measures. High risk patients are those with co-morbidities or risk factors that will
decrease the likelihood of treatment success and increase infection severity (example: anatomically unfavorable
infection or a health careassociated infection).

Table 1: Clinical Factors Predicting Failure of Source Control for

Intra-abdominal Infections (IFI)1
Delay in the initial intervention (>24 hours)
High severity of illness (APACHE II score 15)
Advanced age
Co-morbidity and degree of organ dysfunction
Low albumin level
Poor nutritional status
Degree of peritoneal involvement or diffuse peritonitis
Inability to achieve adequate debridement or control of drainage
Presence of malignancy
NOTE: APACHE, Acute Physiology and Chronic Health Evaluation.

Developed by General Surgery and the Antimicrobial Stewardship Program

Approved by the Antimicrobial Subcommittee/P&T Committee September 2010

Empiric Treatment (Adults)

Table 1: Community Acquired Intra-abdominal Infection

Recommended
Alternative
Tigecycline 100mg IV x 1
dose then 50mg IV every 12
hours OR

Low to Moderate
Risk/Severity

High Risk/Severity
(indluding
immunocompromised
patients)

Ceftriaxone 1-2gm IV every

24 hours PLUS
metronidazole 500mg IV
every 6 hours

Piperacillin/tazobactam
3.375gm IV every 6 hours

Penicillin Allergy (Anaphylaxis)

Tigecycline 100mg IV x 1 dose then 50mg IV

every 12 hours OR
Piperacillin/tazobactam
3.375gm IV every 6 hours

Cefepime 2gm IV every 12

hours PLUS metronidazole
500mg IV every 6 hours

Aztreonam 2gm IV every 8 hours PLUS

metronidazole 500mg IV every 6 hours PLUS
Vancomycin* (Pharm.D. on call for dosing
assistance)

Aztreonam 2gm IV every 8 hours PLUS

metronidazole 500mg IV every 6 hours PLUS
Vancomycin* (Pharm.D. on call for dosing
assistance)

* Vancomycin MUST be added to Aztreonam therapy as this agent only provides coverage for gram-negative aerobic bacteria. Contact
pharmacist for dosing recommendations.
Emphasis should be placed on the timeliness of antimicrobial therapy. Please administer first doses STAT.

Table 2: Healthcare Associated Intra-abdominal Infection (either nosocomial onset or community onset in a patient
with presence of an invasive device, history of MRSA colonization, or recent hospitalization or surgery).
Recommended
Alternative
Penicillin Allergy (Anaphylaxis)
Nosocomial Infection

Piperacillin/tazobactam
4.5gm IV every 6 hours

Cefepime 2gm IV every 8

hours PLUS metronidazole
500mg IV every 6 hours

Aztreonam 2gm IV every 8 hours PLUS

metronidazole 500mg IV every 6 hours PLUS
vancomycin*

Empiric coverage of enterococci is recommended in patients with health-care associated intra-abdominal

infections, and vancomycin (contact pharmacy for dosing recommendations) is recommended. Coverage of
vancomycin-resistant enterococci (VRE) should be employed if patient is known to be colonized with VRE or be at
high-risk for infection (liver transplantation, etc). Agents with coverage of VRE include linezolid, daptomycin, and
tigecycline.

Coverage of
enterococci

Resistant Gramnegative Organisms

Patients known to be colonized with multidrug-resistant gram-negative organisms should receive therapy which
includes coverage of the colonizing organism(s). In these cases, agents other than those listed above may be
necessary (i.e. doripenem, etc.). In penicillin-allergic patients, tigecycline has been shown to be a reasonable
alternative, but provides NO anti-pseudomonal activity. Infectious Diseases consultation is recommended.

Antifungal Therapy

Antifungal therapy with micafungin may be considered in critically ill patients. Antifungal therapy should be used
in patients where fungi are isolated in culture.

* Vancomycin MUST be added to Aztreonam therapy as this agent only provides coverage for gram-negative aerobic bacteria. Contact
pharmacist for dosing recommendations.
-Emphasis should be placed on the timeliness of antimicrobial therapy. Please administer first doses STAT.
-Major Reference (SIS/IDSA Guidelines): Solomkin, et al. Clinical Infectious Diseases 2010; 50:133-64.

Developed by General Surgery and the Antimicrobial Stewardship Program

Approved by the Antimicrobial Subcommittee/P&T Committee September 2010