Administrative Office:

600 University Ave, 449

Toronto, ON BestPracticeinGeneralSurgery
M5G 1X5
T: 416.586.4800 x8534 Guideline#4:
F: 416.586.8644
E: epearsall@mtsinai.on.ca
ManagementofIntraAbdominalInfections

Steering Committee JeffreyDoyle,AveryNathens,AndrewMorris,SandraNelson,RobinMcLeod
Robin McLeod, Chair
Mount Sinai Hospital
Mary-Anne Aarts
AQualityInitiativeoftheBestPracticeinGeneralSurgeryand
Toronto East General Hospital theTorontoAntimicrobialStewardshipCorridor

Cagla Eskicioglu
University of Toronto

Darlene Fenech
Sunnybrook Hospital Section1: GeneralInformation
Process
Shawn Forbes
University of Toronto Rationale
Definitions
David Lindsay
St. Josephs Health Centre
Marg McKenzie
Section2: ProtocolRecommendations
Mount Sinai Hospital
Avery Nathens
Section3: EvidentiaryBase
St. Michaels Hospital
Allan Okrainec Section4: ExternalReviewProcess
Toronto Western Hospital

Lorne Rotstein
Toronto General Hospital

Peter Stotland

North York General Hospital

Alice Wei
Toronto General Hospital

December2011 Page1of26

Section1.GeneralInformationaboutthisGuideline

Aim
Theaimofthisguidelineistomakerecommendationsonthemanagementofcomplicated
intraabdominalinfectionswithregardstosourcecontrolandantibioticchoiceandduration
andmanagementofbiliarytractinfections.

OutcomesofInterest

Eradicationofintraabdominalinfection.

TargetPopulation

Patientswithcomplicatedintraabdominalinfections.

IntendedUsers

Generalsurgeons,infectiousdiseasespecialists,intensivists,andinterventionalradiologists

OverviewofProcess

ThisguidelineconformstorecentrecommendationspublishedjointlybytheSurgicalInfection
SocietyandtheInfectiousDiseasesSocietyofAmerica1,butistailoredforpracticeinthe
UniversityofTorontosDivisionofGeneralSurgeryaspartoftheBestPracticeinGeneral
SurgeryinitiativeinconjunctionwiththeTorontoAntimicrobialStewardshipCorridor.

April2011 Page2of26
RationaleforGuidelineontheAppropriateManagementofIntraAbdominalInfections

ComplicatedIntraAbdominalInfections(cIAIs)areinfectionsthathavespreadbeyondthe
sourceorgantocontaminatetheperitonealcavityandthusaresynonymouswithsecondaryor
tertiaryperitonitis,orareduetoarupturedviscus.cIAIsarefrequentlyencounteredingeneral
surgicalpracticeandareasourceofconsiderablemorbidityandmortality.Appropriate
managementrequirestimelyandappropriateantimicrobialtherapyaswellascontrolofthe
sourceofinfection.

ItisimportanttodistinguishtheantimicrobialtreatmentrequiredforpatientswithcIAIsfrom
thosewithuncomplicatedIAI.Asestablishedinfectionisnotpartofthediseaseprocessin
patientswithuncomplicatedIAI,thesepatientsrequireonlyanultrashortcourseofantibiotics.
Thus,patientswithnonperforatedappendixorsimplecholecystitisrequireadoseof
antimicrobialspriortooperationandnopostoperativeantibiotictreatment.Similarly,patients
withupperGI(stomachandduodenum)perforationsthatundergooperationwithin24hours
andpatientswithtraumatic(blunt,penetrating,oriatrogenic)bowelperforationsoperatedon
within12hoursrequireantibioticsfor24hoursorless1.Patientswithevidenceofaprevious
perforatedfistula(eg:fromCrohnsDiseaseordiverticulitiswithnoevidenceofinfection
shouldreceiveanultrashortcourseofantibiotics.Thisshouldbeconsideredperioperative
prophylacticantibioticsratherthantreatmentofestablishedintraabdominalinfection.

Thepurposeofthisdocumentistoprovideevidencebasedrecommendationsforantimicrobial
therapyaswellassourcecontrolforpatientswithcIAIs.

DefinitionsofKeyTerms(fromtheCanadianPracticeGuidelineforSurgicalIAIs)

UncomplicatedIAIs:theprocessischaracterizedonlybycontaminationorinflammationthat
doesnotextendbeyondthesourceandthediseaseiscompletelyexcisedatthetimeof
operation.e.g.earlytraumaticperforation,simpleappendicitisorcholecystitis..

ComplicatedIAIs(cIAI):theinfectiousprocessproceedsbeyondtheorganthatisthesourceof
theinfection,andcauseseitherlocalizedperitonitis(oftenreferredtoasabdominalabscess)or
diffuseperitonitis,dependingontheabilityofthehosttocontaintheprocesswithinapartof
theabdominalcavity.AcIAIischaracterizedeitherbypusoranexudateatthetimeofsource
control.

CommunityAcquiredIAIs:includeconditionssuchasgastroduodenalperforations,ascending
cholangitis,cholecystitis,appendicitis,diverticulitiswithorwithoutperforation,bowel
perforationandpancreatitisinpatientswithoutprevioussurgicalinterventionor
hospitalization.

HeathCareAssociatedIAIs:includeinfectiousprocessesthatareabsentatthetimeofhospital
admission,butbecomesevident5ormoredaysafteradmission,andincludeanastomoticleaks
andperforationsaswellasabscessesthatdevelopasacomplicationofsurgery.Theyalso

April2011 Page3of26
includeinfectionsacquiredduringthecourseofreceivingtreatmentforotherconditionsina
healthcaresetting,includingnursinghomes,dialysisunitsorsurgicaldaycareunits,withinthe
previous12months.

MildtoModerateSeverity:Notmeetingcriteriaforhighseverity.Thesepatientsaretypically
caredforoutsideoftheICU.

HighSeverity:Infectionscharacterizedbythepresenceoforgandysfunction(e.g.acutelung
injury,hypotension,renaldysfunction)orthoseinfectionsoccurringinacompromisedpatient:
elderly,extensivecomorbidity,immunosuppressed.ThesepatientswilltypicallyrequireICU
care.

April2011 Page4of26
Section2.SummaryofRecommendations

TypeofIAI Examples SelectionofAntibiotics

Spectrumof Recommended PCNAllergic Duration
Antimicrobial Antibiotics Patients
Activity
CommunityAcquiredIAI:Uncomplicated
Uncomplicated Nonperforated Entericgram cefazolin& gentamicin& Preoperatively
IAI appendicitis negativebacilli& metronidazole metronidazole only
anaerobes
Perforation Perforationsof Grampositivecocci cefazolin& gentamicin& Ultrashort
Without stomach& &aerobic/ metronidazole metronidazole 24hoursonly
Established duodenum& facultative
Infection traumaticbowel anaerobes
perforationswho +/anaerobes
aretakentotheO.R.
within12to24hrs
CommunityAcquiredIAI:Complicated
Mildto Perforated Entericgram cefazolin(iv) gentamicin& 37days(until
Moderate appendicitis; negativebacilli& orcephalexin metronidazole clinicalsigns
Severity perforated anaerobes (po)& ofresolution)
diverticulitis metronidazole
HighSeverity Shock;neworgan Entericgram ceftriaxone& gentamicin& 37days(until
failure;ICUpatient negativebacilli& metronidazole, metronidazole clinicalsigns
anaerobes; (mayconsider ofresolution)
possibly piperacillin
enterococcus tazobactam)
Otherrisk Age>70; Entericgram ceftriaxone& gentamicin& 37days(until
factorsfor immunosuppression; negativebacilli& metronidazole metronidazole clinicalsigns
treatment poornutrition; anaerobes; (mayconsider ofresolution)
failure delayed/inadequate possibly piperacillin
sourcecontrol enterococcusin tazobactam)
immunosuppressed
HealthCareAssociatedcIAI
Mildto Hospitalized5 Enterococcus, piperacillin vancomycin, 37days(until
Moderate days;anastomotic drugresistant tazobactam* gentamicin& clinicalsigns
leak;postoperative gramnegative (mayconsider metronidazole ofresolution)
abscess bacilli ceftriaxone& OR
metronidazole) carbapenem**
(meropenem
orimipenem)
&vancomycin
HighSeverity Hospitalized5 Enterococcus, piperacillin vancomycin, 37days(until
days;anastomotic drugresistant tazobactam* gentamicin& clinicalsigns
leak;shock;ICU gramnegative metronidazole ofresolution)
bacilli OR
carbapenem**
(meropenem
orimipenem)
&vancomycin

April2011 Page5of26
 Otherrisk Nursinghome; Enterococcus,drug piperacillin vancomycin, 37days(until
factorsfor rehabfacility; resistantgram tazobactam* gentamicin& clinicalsigns
HealthCare dialysispatient; negativebacilli (mayconsider metronidazole ofresolution)
Associated recentantibiotics ceftriaxone& OR
Infection metronidazole) carbapenem**
(meropenem
orimipenem)
&vancomycin
BiliaryTract
Mildto Ascending Entericgram cefazolin gentamicin 37days(until
Moderate cholangitis;acute negativebacilli clinicalsigns
calculous ofresolution)
HighSeverity cholecystitis Entericgram ceftriaxone& gentamicin& 37days(until
negativebacilli ampicillin vancomycin clinicalsigns
ofresolution)

*Addfluconazoleifyeastidentifiedinperitonealsamples
**Riskofcrossreactivitybetweenpenicillinandcarbapenemsisconsideredtobe1%

April2011 Page6of26
Part1:ComplicatedIntraAbdominalInfections

1.SelectionofEmpiricAntimicrobialAgents

1.1 PatientswithmildtomoderatecommunityacquiredIAIrequireempiriccoverage
forentericgramnegativebacilliandanaerobes.Cefazolinandmetronidazoleare
recommended.InpatientswithIgEmediatedallergyorotherseverereactionto
betalactams,Gentamicinandmetronidazolearerecommended.
1.2 MostpatientswithmildtomoderatecommunityacquiredIAIdonotrequire
coverageofEnterococcusspp.unlessotherriskfactorsarepresent.
1.3 PatientswithhighseveritycommunityacquiredIAImaybenefitfrombroader
coverageagainstgramnegativebacilli.Ceftriaxoneandmetronidazoleare
recommendedorgentamicinandmetronidazoleforIgEmediatedallergyorother
severereactiontobetalactams.Piperacillintazobactamcouldalsobeconsidered.
1.4 MostpatientswithhealthcareassociatedIAIshouldreceivebroadspectrumempiric
antimicrobialtherapy,includingcoveragefordrugresistantgramnegativebacilli
andEnterococcusspp.Piperacillintazobactamisrecommendedforthosewithhigh
severitydisease.Somepatientswithmildmoderateseverityhealthcareassociated
IAImaynotrequireasbroadofcoverageandthus,ceftriaxoneandmetronidazole
maybeappropriate.InpatientswithIgEmediatedpenicillinallergyorothersevere
reaction,vancomycin,gentamicinandmetronidazoleORvancomycinplusa
carbapenemarerecommended.
1.5 PatientswithhealthcareassociatedIAIshouldreceiveantifungaltherapyifyeast
areidentifiedinperitonealsamples.Fluconazoleshouldbetheempiricagentof
choiceinthemajorityofpatients.PatientswithcommunityacquiredIAIlikelydonot
requireantifungaltherapy.

2.TimingandDurationofAntimicrobialTherapy
2.1 AntimicrobialtherapyshouldbeinitiatedoncecIAIisdiagnosedorconsideredlikely.
2.2 MostpatientswithcIAIrequireantimicrobialtherapyfor37daysaftersource
control.
2.3 Aftersourcecontroliscomplete,antimicrobialtherapyshouldbediscontinuedwhen
clinicalsignsofinfectionhaveimproved,usually37daysaftersourcecontrol.Oral
stepdowntherapyisrarelyrequired,withtheexceptionofpatientswithperforated
appendicitisorperforateddiverticulitis,inwhomaveryshortlengthofstay
precludesathoroughassessmentofclinicalresponse.Inthesepatients,atotalofa
5daycourse(withatransitiontooralceflexin)isreasonable.Aprolongedcourseof
antimicrobials(>7days)shouldbeavoidedunlesssourcecontrolisincomplete.
2.4 Patientswithevidenceofongoinginfectionat47daysshouldbereevaluatedfor
sourcecontrolratherthancontinuingwithaprolongedcourseofantimicrobials.

3.UseofCultureandSensitivitySpecimenstoGuideAntimicrobialTherapy
3.1 BloodculturesshouldonlybeobtainedifthediagnosisofIAIisunclearorifthereis
ahighsuspicionofbacteremia.

April2011 Page7of26
 3.2 Peritonealsamplesshouldnotberoutinelyobtainedinmildtomoderate
communityacquiredIAI.
3.3 PeritonealsamplesshouldbeobtainedinallpatientswithhealthcareassociatedIAI
andhighseveritycommunityacquiredIAI.
3.4 Peritonealfluidshouldbesenttothelabinaerobicandanaerobicbloodculture
bottles.

4.SourceControl
4.1 AllpatientswithIAIshouldundergoevaluationforapotentiallycontrollablesource
ofinfection.
4.2 Percutaneousdrainageisthepreferredsourcecontroltechniqueforlocalized
abscesses.
4.3 OperativesourcecontrolshouldbeundertakenformostpatientswithcIAInot
amenabletopercutaneousdrainage.Theprinciplesoftheoperationshouldbeto
draininfectedfluid,debridenonviabletissueandcontrolcontinuedcontamination
byresectionofthesourceorganorbygastrointestinaltractdiversion.
4.4 Anondemandrelaparotomystrategyispreferredoverplannedrelaparotomyor
laparostomy(openabdomen)strategiesinmostcasesofcIAI.
4.5 Laparostomyshouldonlybeemployedforspecificindications:intraabdominal
hypertension,mesentericischemia,necrotizingabdominalwallinfection,or
damagecontrolsurgery(withintestinaldiscontinuityorincompletesourcecontrol).
4.6 Thereiscurrentlyinsufficientevidencetomakearecommendationaboutprimary
colonicanastomosisversusstomainthesettingofperitonitis.Patientswithless
severesepsismightbesafelymanagedwithprimaryanastomosis.

Part2:BiliaryTractInfections

5.BiliaryTractInfections
5.1 Allpatientswithascendingcholangitisshouldreceiveantimicrobialtherapy.
Patientswithacutecalculouscholecystitisshouldreceiveantimicrobialtherapyif
thereisanincreasedlikelihoodofbactibilia(fever,leukocytosis,advancedage,
immunosuppressionordiabetes)orasuspicionofsuperimposedinfection(adjacent
abscess,airinthegallbladderwallorlumen,orsuspicionofperforation).
5.2 Allpatientswithacutecholecystitistakentotheoperatingroomshouldreceive
antibioticprophylaxispriortoskinincision.Ifthecholecystitisisuncomplicatedthen
nofurtherantibioticsarerequiredaftercholecystectomy.Incasesofcomplicated
cholecystitischaracterizedbyeitherperforation,gangrene,orempyema,the
antimicrobialdurationshouldconformtothedurationofantimicrobialtherapyfor
cIAIdetailedinSection2,TimingandDurationofAntimicrobialTherapy.
5.3 Patientswithbiliaryinfectionshouldreceiveantibioticstocoverentericgram
negativeorganisms.Cefazolinisrecommendedinmildtomoderatecasesand
ceftriaxoneandampicillininpatientsmeetingcriteriaforahighseverityinfection.
Onlypatientswithbiliaryentericanastomosesrequireanaerobiccoverage,suchas

April2011 Page8of26
 metronidazole.ForIgEmediatedorotherseverereactiontobetalactams,
gentamicinorgentamicinandvancomycinshouldbeused.
5.4 Patientswithascendingcholangitisshouldreceivepromptdecompressionofthe
commonbileduct.Endoscopicorpercutaneousapproachesarepreferredtoopen
commonbileductexplorationwheneverfeasible.
5.5 Patientswithacutecalculouscholecystitisshouldbeconsideredforearly
laparoscopiccholecystectomy(within7296hoursofsymptomonset).
5.6 ProphylacticantibioticsshouldNOTbeadministeredtopatientswithnecrotizing
pancreatitis.

April2011 Page9of26
Section3.RecommendationsandKeyEvidence

1.SelectionofEmpiricAntimicrobialAgents

1.1 PatientswithmildtomoderatecommunityacquiredIAIrequireempiriccoverage
forentericgramnegativebacilliandanaerobes.Cefazolinandmetronidazoleare
recommended.InpatientswithIgEmediatedallergyorotherseverereactionto
betalactams,Gentamicinandmetronidazolearerecommended.
1.2 MostpatientswithmildtomoderatecommunityacquiredIAIdonotrequire
coverageofEnterococcusspp.unlessotherriskfactorsarepresent.
1.3 PatientswithhighseveritycommunityacquiredIAImaybenefitfrombroader
coverageagainstgramnegativebacilli.Ceftriaxoneandmetronidazoleare
recommendedorgentamicinandmetronidazoleforIgEmediatedallergyorother
severereactiontobetalactams.Piperacillintazobactamcouldalsobeconsidered.
1.4 MostpatientswithhealthcareassociatedIAIshouldreceivebroadspectrum
empiricantimicrobialtherapy,includingcoveragefordrugresistantgramnegative
bacilliandEnterococcusspp.Piperacillintazobactamisrecommendedforthose
withhighseveritydisease.Somepatientswithmildmoderateseverityhealth
careassociatedIAImaynotrequireasbroadofcoverageandthus,ceftriaxoneand
metronidazolemaybeappropriate.InpatientswithIgEmediatedpenicillinallergy
orotherseverereaction,vancomycin,gentamicinandmetronidazoleOR
vancomycinplusacarbapenemarerecommended.
1.5 PatientswithhealthcareassociatedIAIshouldreceiveantifungaltherapyifyeast
areidentifiedinperitonealsamples.Fluconazoleshouldbetheempiricagentof
choiceinthemajorityofpatients.PatientswithcommunityacquiredIAIlikelydo
notrequireantifungaltherapy.

SummaryofEvidence

WhenselectingantimicrobialtherapyforcIAIs,acleardistinctionmustbemadebetween
patientswithcommunityacquiredIAIandthosewithhealthcareassociatedcIAI.Patientswho
havebeenhospitalizedfor5ormoredays2,whohavereceivedpreviousantibiotictherapywith
activityagainstentericorganisms,orwhoarepostoperative3undergoanotableshiftintheir
bacterialflora,resultinginagreaternumberofsignificantinfectionsfromEnterococcusspp.,
Staphylococcuaureus,drugresistantgramnegativebacillisuchasPseudomonasspp.,and
yeast4.Patientsfromnursinghomesandrehabilitationfacilitiesandonchronicdialysisshould
alsobeconsideredatriskofharbouringresistantorganisms.Althoughtherearenodatafrom
thesepopulationsspecificforcIAI,shiftsinnursinghomepatientsbacterialflorahasbeenwell
documentedinotherinfectionssuchasbacterialpneumonia.

Ingeneral,patientswithIAIrequiretherapythatcoversentericgramnegativebacilliand
anaerobes.Patientswithproximalgastrointestinalperforations,includingstomach,duodenum
andproximaljejunum,requirecoverageonlyforgrampositivecocciandaerobic/facultatively
anaerobicgramnegativebacteria,providedthereisnoobstruction,malignancyoracid

April2011 Page10of26
suppressingtherapy.Patientswithbiliaryinfectionsusuallyrequirecoverageonlyforenteric
gramnegativebacilli(seeBiliaryInfections,Section5).

PatientswithcommunityacquiredIAIsshouldbeassessedfortheseverityoftheinfection.
ThosepatientswithneworganfailureorareinshockandrequirecareinanIntensiveCareUnit
(ICU)shouldbeclassifiedashighseverity.Somepatientsathighriskoftreatmentfailureonthe
basisofadvancedage(>70yearsold),immunosuppression,poornutritionalstatus,ordelayed
orinadequatesourcecontrol),mayalsobeconsideredtohavehighseverityinfections.
PatientswithmildtomoderatecommunityacquiredIAIsrequireantimicrobialcoverage
directedagainstentericgramnegativeandanaerobicbacteria,suchascefazolinand
metronidazole.Thereisincreasingworldwideandlocalresistancetofluoroquinolonesamong
gramnegativebacteria.RecentantibiogramdatafromthreeUniversityofTorontoteaching
hospitalsindicatethat31%ofnonICUE.coliisolatesareresistanttociprofloxacinwhereasonly
15%areresistanttogentamicin. Oncedailydosingofaminoglycosides(57mg/kg)hasbeenin
useforapproximately15yearswiththerationaleofdecreasednephrotoxicityandototoxicity
asittakesadvantageoftheconcentrationdependentkillingeffectsofaminoglycosidesand
thereforeallowsforaperiodoftimewherethekidneyandeararefreefromdrugexposure.As
well,nephrotoxicitywithaminoglycosidesisnotanacuteeventandisassociatedwithduration
longerthan7days.Therefore,becauseofthehighresistanceratestofluoroquinolonesand
lowriskofnephrotoxicitywithappropriatedosingandshortcoursesof
aminoglycosides,.patientswithIgEmediatedorotherseverereactionstobetalactam
antibioticsshouldbetreatedwithgentamicinandmetronidazole.Patientswithhighseverity
communityacquiredIAIsarepresumablyatgreaterriskofadverseeventsintheeventof
treatmentfailureandthusshouldlikelyreceivebroadergramnegativecoverage,suchas
ceftriaxoneandmetronidazole,althoughtherearenotrialdatatosupportthis
recommendation.

MostpatientswithcommunityacquiredIAIsdonotrequireempiriccoverageagainst
Enterococcusspp1.Antibioticswhichcoverenterococciincludeampicillin,vancomycinand
piperacillintazobactam,butnotcephalosporinsorfluoroquinolones.Antimicrobialregimens
coveringenterococcihavenotbeenshowntoimproveoutcomesinthispatientpopulation5.
Theexceptionstothisrecommendationarepatientswithhighseverityinfections,particularly
thoserequiringICUcareorwhoareimmunosuppressed6.

PatientswithhealthcareassociatedIAIsrequirebroadercoveragethanthosewith
communityacquireddisease7.Asnotedabove,Enterococcusspp.8anddrugresistantgram
negativebacilliaremorelikelytocausesignificantIAIinthissetting.Thisisparticularlytruein
postoperativepatients,manyofwhomhavebeenexposedtoantibiotics,suchas
cephalosporinsandfluoroquinolones,whichlacksignificantactivityagainstthesemore
resistantorganisms.Whenpossible,patientswhohavereceivedpreviousantibioticsshould
havebroadercoverageinitiated.Ideally,adifferentclassofantibioticsshouldbeselectedin
thesepatients.PatientswithhealthcareassociatedIAIsshouldhaveintraoperative
peritonealculturessentasthesemayallowidentificationofpotentiallyimportantpathogens
suchasmultidrugresistant(MDR)gramnegativebacilliandyeast.Somepatientswithhealth

April2011 Page11of26
careassociatedIAIwhoareclinicallywellandhavehadminimalexposuretobroadspectrum
antibiotics(i.e.asingleperioperativedose)maybeconsideredfortreatmentwithagentssuch
asceftriaxoneandmetronidazolethatlackactivityagainstMDRpathogens.Patientswhoare
criticallyillshouldhavebroadercoverageinitiated,suchaspiperacillintazobactam.

PatientswithhealthcareassociatedIAIwhohaveyeastidentifiedongramstainorculture
shouldhaveantifungaltherapyinitiated9.Fluconazoleshouldbetheempiricantifungalagent
ofchoiceinmostpatients.PatientsknowntobecolonizedwithnonalbicansCandidaspecies,
suchasC.glabrataorC.krusei,orcriticallyillpatientsintheICUwithriskfactorsfornon
albicansfungalinfectionshouldreceivebroaderempiriccoverage,atleastuntilthesensitivities
areknown10.AnInfectiousDiseasesconsultisrecommendedinthesecircumstancestoaidwith
appropriateantifungalselection.PatientswithhealthcareassociatedIAImaybenefitfrom
empiricantifungaltherapyiftheyhavebeenonprolongedbroadspectrumantibioticsandhave
incompletesourcecontrol.

PatientswithhealthcareassociatedIAIandsevereIgEmediatedbetalactamallergyare
difficulttotreat.Optionsincludevancomycin,gentamicinandmetronidazole,acceptingan
increasedriskofacutekidneyinjury,orvancomycinplusacarbapenem(suchasimipenemor
meropenem).Carbapenemshave<1%riskofcrossreactivitytootherbetalactamagents.

2.TimingandDurationofAntimicrobialTherapy

2.1 AntimicrobialtherapyshouldbeinitiatedoncecIAIisdiagnosedorconsidered
likely.
2.2 MostpatientswithcIAIrequireantimicrobialtherapyfor37daysaftersource
control.
2.3 Aftersourcecontroliscomplete,antimicrobialtherapyshouldbediscontinued
whenclinicalsignsofinfectionhaveimproved,usually37daysaftersource
control.Oralstepdowntherapyisrarelyrequired,withtheexceptionofpatients
withperforatedappendicitisorperforateddiverticulitis,inwhomaveryshort
lengthofstayprecludesathoroughassessmentofclinicalresponse.Inthese
patients,atotalofa5daycourse(withatransitiontooralceflexin)isreasonable.
Aprolongedcourseofantimicrobials(>7days)shouldbeavoidedunlesssource
controlisincomplete.
2.4 Patientswithevidenceofongoinginfectionat47daysshouldbereevaluatedfor
sourcecontrolratherthancontinuingwithaprolongedcourseofantimicrobials.

SummaryofEvidence

AntimicrobialtherapyshouldbeinitiatedonceadiagnosisofcIAIismadeorconsideredlikely1.
Forpatientswithseveresepsis(associatedwithhypotensionorneworganfailure)thereis
someevidencetosuggestthatdelayininitiatingantimicrobialtherapyincreasesmortality11.
ThereislittleevidencetomakerecommendationswithrespecttoantimicrobialdurationinIAI.
Antimicrobialtherapylastinggreaterthan7daysshouldbeconsideredaprolongedcourse.

April2011 Page12of26
Antimicrobialsshouldonlybegivenforaprolongedcourseincircumstanceswheresource
controlhasbeendeemedinadequate.Thereareretrospectivedatatosuggestthatpatients
whoreceiveshortercoursesofantibioticshavenoincreaseininfectiveorothercomplications
versusthosewhoreceivelongercoursesofantibioticswhenstratifiedbydegreeof
contamination12.Asmall,prospectivetrialofpatientswithmildtomoderatecommunity
acquiredIAIdemonstratedthatpatientstreatedwith3daysofertapenemhadnoincreasein
treatmentfailureorinfectiouscomplicationscomparedtoastandard(5day)course13.
FurthertrialsofantimicrobialdurationinIAIarecurrentlyunderwayatthetimeofthis
guidelinespublication.MostpatientswithIAIonlyrequireantimicrobialtherapyuntilclinical
evidenceofimprovinginfectionoccurs14,ascharacterisedbynormalizationofthewhiteblood
cell(WBC)count,absenceoffeverandreturnofbowelfunction.Patientswhodonot
demonstrateimprovementofclinicalsignsofIAIat47daysshouldbereimagedforevidence
ofongoingIAIamenabletofurthersourcecontrolratherthancontinuingonprolongedcourses
ofantimicrobialtherapy.

Therearelittledatatoinformtherationaluseofantimicrobialsinthecontextofalocalized
abscessundergoingpercutaneousdrainage.Periproceduralantimicrobialcoverageshouldbe
providedinallcases.Incaseswhereclinicalsignsofinfectionareminimalorresolverapidly,
antimicrobialtherapymayberapidlydiscontinued.Oneprospectiveseriesdemonstratedthat
patientswithlocalizedperitonitisorabscessestreatedwith48hoursofantibioticsaftersource
controlhadalowrateofinfectiouscomplications15.Percutaneousdrainageandoperative
sourcecontrolshouldbeconsideredequivalentwhendetermininganappropriatedurationof
antimicrobials.

PatientswithbacteremiaarisingfromIAIcaninmostcircumstancesbetreatedforthesame
durationasanonbacteremeicpatient,guidedbytheimprovementoftheirclinicalstatus.One
definiteexceptionisStaphylococcusaureusbacteremiawhichshouldbetreatedforaminimum
of2weeks.AnInfectiousDiseaseconsultshouldbeobtainedonpatientswithenterococcalor
Staphylococcusaureusbacteremiaasthereisapotentialformetastaticinfection.These
patientstypicallyrequirelongercoursesofantimicrobialtherapy.

InmostcasesofcIAI,stepdowntooralantimicrobialsisunnecessary.Apatientwhohas
receivedsourcecontrolandacourseofeffectiveantimicrobialtherapyandwhodemonstrates
improvementorresolutioninclinicalsymptomsshouldhaveantimicrobialtherapy
discontinuedratherthanchangedtooralagents.Inrarecircumstances,patientswith
incompletesourcecontrolorincompleteresolutionofclinicalsymptomsmaybedischarged
homewithoralantimicrobials.Acceptableregimenswouldincludecephalexinand
metronidazole,amoxicillinclavulanicacid,cotrimoxazoleandmetronidazole,ora
fluoroquinoloneplusmetronidazole.Theincreasingresistanceofentericgramnegativebacilli
tofluoroquinolonesshouldagainbeemphasized,whichislikelydriventosomedegreeby
excessiveoutpatientprescribingofprolongedoralcoursesoffluoroquinolones.

April2011 Page13of26

3.UseofCultureandSensitivitySpecimenstoGuideAntimicrobialTherapy

3.1 BloodculturesshouldonlybeobtainedifthediagnosisofIAIisunclearorifthere
isahighsuspicionofbacteremia.
3.2 Peritonealsamplesshouldnotberoutinelyobtainedinmildtomoderate
communityacquiredIAI.
3.3 Peritonealsamplesshouldbeobtainedinallpatientswithhealthcareassociated
IAIandhighseveritycommunityacquiredIAI.
3.4 Peritonealfluidshouldbesenttothelabinaerobicandanaerobicbloodculture
bottles.

SummaryofEvidence

BloodculturesareoflittlevalueinpatientswithIAIwithyieldsreportedfrom0to5%.Theyield
ofbloodculturesmaybehigherinimmunocompromisedpatients,suchassolidorgan
transplantrecipients.Peritonealsamplesshouldbeobtainedfrompatientswithhighseverity
communityacquiredIAIand,especially,healthcareassociatedIAI.Thesepatientshavean
increasedincidenceofdrugresistantorganismsandwilllikelybenefitfromtherapytailoredto
peritonealcultureresults.PatientswithmildtomoderatecommunityacquiredIAIdonot
requireroutineperitonealsamplesastheserarelyaltermanagementoraffectoutcomeevenif
resistantorganismsareidentified16.Forperitonealsampling,cultureswabsprovidesuboptimal
yield.Ideally,110mLofrepresentativefluidshouldbesenttothelabinbothaerobicand
anaerobicculturebottles.Additionalfluidmaybesentforgramstainandfungalcultures.

4.SourceControl

4.1 AllpatientswithIAIshouldundergoevaluationforapotentiallycontrollable
sourceofinfection.
4.2 Percutaneousdrainageisthepreferredsourcecontroltechniqueforlocalized
abscesses.
4.3 OperativesourcecontrolshouldbeundertakenformostpatientswithcIAInot
amenabletopercutaneousdrainage.Theprinciplesoftheoperationshouldbeto
draininfectedfluid,debridenonviabletissueandcontrolcontinued
contaminationbyresectionofthesourceorganorbygastrointestinaltract
diversion.
4.4 Anondemandrelaparotomystrategyispreferredoverplannedrelaparotomyor
laparostomy(openabdomen)strategiesinmostcasesofcIAI.
4.5 Laparostomyshouldonlybeemployedforspecificindications:intraabdominal
hypertension,mesentericischemia,necrotizingabdominalwallinfection,or
damagecontrolsurgery(withintestinaldiscontinuityorincompletesource
control).

April2011 Page14of26
 4.6 Thereiscurrentlyinsufficientevidencetomakearecommendationaboutprimary
colonicanastomosisversusstomainthesettingofperitonitis.Patientswithless
severesepsismightbesafelymanagedwithprimaryanastomosis.
SummaryofEvidence

AllpatientswithsuspectedIAImustbeevaluatedforasourceofinfectionamenabletosurgical
orpercutaneoussourcecontrol.ThismaybeaccomplishedbyphysicalexamorplainXrays,
butmoreoftenrequiresComputedTomography(CT)scanning.Ideally,patientswithcIAI
shouldundergosourcecontrolwithin24hoursofpresentation1.Thosewhopresentwith
severesepsisorsepticshockshouldundergosourcecontrolwithin6hours,asrecommendedin
theSurvivingSepsisGuidelines17.Closeattentionmustbepaidtotheresuscitationofsuch
patientsandtheymaybenefitfromdedicatedresuscitationinanICUpriortosourcecontrol,
providedthesourcecontrolprocedureisnotundulydelayed.

Ifalocalizedabscessisidentifiedasthesourceofinfectionbyphysicalexamandimaging
studies,percutaneousdrainageviaimageguidedtechniquesisthepreferredmanagement,
resultingingoodcurerateswithalowincidenceofcomplications18.Percutaneousdrainageis
notindicatedforpatientswithclinicalevidenceofgeneralizedperitonitisorwithdiffusefreeair
orfreefluidonimaging.Theresolutionofintraabdominalabscessesshouldbeconfirmedbya
followupCTscanaswellasabsentorminimaldrainage(lessthan10mL/24hrs)fromthedrain
andaresolutionofclinicalsignsofinfection19.Absenceofanyoftheseconditionsshould
promptconsiderationoffurthersourcecontrol.Somepatientswillrequirerepeatdrainage,
catheterexchangeor,rarely,subsequentoperation20.Reimagingtoguidefurther
percutaneousdrainageattemptsmaybeundertakenasearlyas48hourspostprocedurein
patientswhofailtoimprove.Multipleattemptsatdrainagemayberequiredandshouldnotbe
consideredafailureofthetechnique.

Operativesourcecontrolisrequiredformostpatientswhoarenotsuitableforpercutaneous
drainage.Therearemanyacceptablesurgicalapproaches,dependingontheorganinvolved,
degreeofcontaminationandpatientsclinicalcondition,theexactselectionofwhichisbeyond
thescopeofthisdocumenttoreview.TheprinciplesofsurgicalsourcecontrolforIAIareto
draininfectedfluidandtodebrideorresectanynonviabletissue.However,extensive
debridementoffibrinousdebrishasnotbeendemonstratedtoimproveoutcomeina
randomizedcontrolledtrialofsurgicalsourcecontrolforcIAI21.Controlofongoing
contaminationmayrequireresectionofthesourceorgan,diversionofthegastrointestinaltract
orplacementofdrains.

PatientswithIAIarebestmanagedwithanondemandrelaparotomyapproachinthemajority
ofcases.Inawellconducted,multicenter,randomizedcontrolledtrial,patientstreatedwith
ondemandrelaparotomyhadsimilarmorbidityandmortality,shorterICUandhospitalstays,
andweresparedunnecessaryoperations,comparedtoaplannedrelaparotomyapproach22.
Withtheondemandstrategy,ahighindexofsuspicionmustbemaintainedforongoingIAI,
particularlyinthosepatientswhomanifestneworpersistentorganfailureaftertheirindex
operation23.

April2011 Page15of26

Anopenabdomenstrategy(alsoknownaslaparostomy)shouldrarelybeemployedforthe
managementofIAI,andonlyforspecificindications:knownorsuspectedintraabdominal
hypertension,mesentericischemiarequiringrelooklaparotomy,necrotizingabdominalwall
infection,orprofoundhemodynamicinstabilityrequiringdamagecontrollaparotomy
techniques(suchasintestinaldiscontinuityorincompletesourcecontrol)24.Thedisadvantages
oftheopenabdomenincludeongoingfluidandproteinloss,retractionoftheabdominalwall
musculatureresultinginlossofabdominaldomainandpostoperativehernia,ahighincidence
ofentericfistulae,andpotentiallyaprolongationofthesystemicinflammatoryresponse.

Thereisongoingcontroversyregardingthesafetyofprimarycolonicanastomosisinthesetting
ofperitonitis.Moststudiesonthissubjecthavebeenretrospectiveandsubjecttoconsiderable
selectionbias25.Patientswithlesssevereperitonitisarelikelysafelymanagedwithprimary
anastomosis,althoughthishasnotbeenthesubjectofarandomizedcontrolledtrial.Theuseof
ascoringsystemsuchasthePeritonitisSeverityScoreortheMannheimPeritonitisIndexmay
helptoidentifypatientswhocansafelybemanagedwithprimaryanastomosis26.

5.BiliaryInfections

5.1 Allpatientswithascendingcholangitisshouldreceiveantimicrobialtherapy.
Patientswithacutecalculouscholecystitisshouldreceiveantimicrobialtherapyif
thereisanincreasedlikelihoodofbactibilia(fever,leukocytosis,advancedage,
immunosuppressionordiabetes)orasuspicionofsuperimposedinfection
(adjacentabscess,airinthegallbladderwallorlumen,orsuspicionofperforation).
5.2 Allpatientswithacutecholecystitistakentotheoperatingroomshouldreceive
antibioticprophylaxispriortoskinincision.Ifthecholecystitisisuncomplicated
thennofurtherantibioticsarerequiredaftercholecystectomy.Incasesof
complicatedcholecystitischaracterizedbyeitherperforation,gangrene,or
empyema,theantimicrobialdurationshouldconformtothedurationof
antimicrobialtherapyforcIAIdetailedinSection2,TimingandDurationof
AntimicrobialTherapy.
5.3 Patientswithbiliaryinfectionshouldreceiveantibioticstocoverentericgram
negativeorganisms.Cefazolinisrecommendedinmildtomoderatecasesand
ceftriaxoneandampicillininpatientsmeetingcriteriaforahighseverityinfection.
Onlypatientswithbiliaryentericanastomosesrequireanaerobiccoverage,suchas
metronidazole.ForIgEmediatedorotherseverereactiontobetalactams,
gentamicinorgentamicinandvancomycinshouldbeused.
5.4 Patientswithascendingcholangitisshouldreceivepromptdecompressionofthe
commonbileduct.Endoscopicorpercutaneousapproachesarepreferredtoopen
commonbileductexplorationwheneverfeasible.
5.5 Patientswithacutecalculouscholecystitisshouldbeconsideredforearly
laparoscopiccholecystectomy(within7296hoursofsymptomonset).
5.6 ProphylacticantibioticsshouldNOTbeadministeredtopatientswithnecrotizing
pancreatitis.

April2011 Page16of26


SummaryofEvidence

Biliaryinfectionsdiscussedhereinincludeacutecholecystitisandascendingcholangitis.
Althoughacutecalculouscholecystitisgenerallybeginsasasterileinflammatoryprocess,a
significantfractionofpatients(4070%inmostreports)willdevelopbactibilia,particularlyifthe
timecourseofthediseaseprogressesbeyond48hours27,althoughpredictivemodelsfor
patientswithbactibiliainthesettingofacutecholecystitisareimperfect.Patientswith
bactibiliaareatincreasedriskforinfectiouscomplications,whichmayincludegallbladder
gangreneorperforation,intraabdominalabscessorpostoperativewoundinfection28.

Antimicrobialtherapyisindicatedforallcasesofknownorsuspectedascendingcholangitis.
Manycasesofacutecalculouscholecystitisshouldreceiveantimicrobialtherapy,unlessthey
aremildcases.Specifically,anypatientwithacutecholecystitisandafeverorelevatedWBC
countorwithimagingevidenceofinfection(airinthegallbladderlumenorgallbladderwall,or
intraabdominalorhepaticabscess)shouldreceiveantimicrobialtherapy.Patientswhoare
elderly,immunosuppressedorwhohavediabetesalsohaveahigherriskofinfectionand
shouldreceiveantimicrobialtherapy.Patientswithevidenceofintensegallbladder
inflammation(suchasapalpablegallbladderorrightupperquadrantperitonitis)arealsoat
higherriskofinfection.Allpatientswithacutecholecystitiswhoareundergoing
cholecystectomyshouldhaveantibioticsadministeredpriortoskinincisionasprophylaxisfor
surgicalsiteinfections.Incasesofsimplecholecystitis(withoutruptureorperitonealcavity
contamination)antimicrobialsshouldbediscontinuedaftersourcecontroliscomplete.
Patientswithcomplicatedacutecholecystitisshouldreceiveantimicrobialtherapyuntilclinical
signsofIAIhaveresolved,asdetailedinSection2,TimingandDurationofAntimicrobial
Therapy.

Theorganismsmostfrequentlyinvolvedinbiliaryinfectionareentericgramnegativebacilli,
withenterococciandanaerobeslessfrequentlyidentified.Assuch,patientswithbiliary
infectionrequirecoverageagainstgramnegativebacilli:cefazolinisrecommendedinmost
cases.Ceftriaxoneisrecommendedinsevereinfections.Onlypatientswithbiliaryenteric
anastomosesrequireanaerobiccoverageforbiliaryinfections.Considerationofenterococcal
coverageforbiliaryinfectionsshouldconformtothepreviouslydetailedindicationsfor
enterococcalcoverageinSection1ofthisguideline.Ofnote,livertransplantrecipientswith
ascendingcholangitisareathighriskofenterococcalinfection.

AswithotherIAIs,patientswithbiliaryinfectionmustundergoevaluationforsourcecontrolas
earlyasisfeasible.Forascendingcholangitis,decompressionofthecommonbileductshould
beundertakeninallexceptmildcases,whichmayresolvewithantibiotictherapyalone29.This
ispreferablyachievedwithEndoscopicRetrogradeCholangiography(ERC)combinedwith
sphincterotomyand/orstenting.PercutaneousTranshepaticCholangiography(PTC)isanother
minimallyinvasivemodalitythatmaybeemployedifERCisnotavailableorfeasible.The

April2011 Page17of26
mortalityofopencommonbileductexplorationinacutelyillpatientswithascending
cholangitisishighandthusshouldbeavoidedifERCorPTCcanachieveductal
decompression30.

Patientswithacutecalculouscholecystitisshouldbeconsideredforearlylaparoscopic
cholecystectomy.ArecentCochranereviewnotednoincreaseinadverseeventsandashorter
hospitalstaywithearly(within7daysofsymptomonset)versusdelayedlaparoscopic
cholecystectomy.Ofnote,17.5%ofpatientsinthedelayedgrouphadtoundergoemergency
laparoscopiccholecystectomyduetopersistentorrecurrentsymptoms,withaveryhighrateof
conversiontoopencholecystectomy(45%)31.However,itmustbenotedthatrarebut
importantadverseeventssuchasbileductinjurymaynotbeadequatelycapturedbysmallor
moderatelysizedrandomizedcontrolledtrials,suchasthoseincludedintheCochranereview.
Thosepatientswithsevereacutecholecystitis(associatedwithneworganfailureorneedfor
ICUadmission)arelikelybettertreatedwithpercutaneouscholecystostomyratherthanopen
orlaparoscopiccholecystectomy26.

Patientswithacutepancreatitisshouldnotreceiveantimicrobialtherapyunlessthepancreatitis
iscomplicatedbyascendingcholangitis,ordocumentedorstronglysuspectedinfected
pancreaticnecrosis32.Thepresenceofpancreaticnecrosisaloneisnotanindicationfor
prophylacticantimicrobialtherapy,andsuchtreatmentriskstheselectionofresistant
organisms.Recentrandomizedcontrolledtrialsdemonstratenobenefittoprophylactic
antibioticadministrationinpatientswithnecrotizingpancreatitis3334.

April2011 Page18of26
Section4.ExternalReviewProcess

ReviewerCommentsandResponses

ReviewerComment:FormildtomoderateIAIsuggestinggentamicinforpenicillinallergicpatients,
makesmenervous.WehardlyusegentamicinatSBbecauseofnephrotoxicityandhavingtomonitor
levelsetcinpatientwhomayalreadybedehydratedandhaverenalissues.
AuthorsResponse:RecentantibiogramdatafromthreeUniversityofTorontoteachinghospitals
indicatethat31%ofnonICUE.coliisolatesareresistanttociprofloxacinwhereasonly15%are
resistanttogentamicin. Oncedailydosingofaminoglycosides(57mg/kg)hasbeeninusefor
approximately15yearswiththerationaleofdecreasednephrotoxicityandototoxicityasit
takesadvantageoftheconcentrationdependentkillingeffectsofaminoglycosidesand
thereforeallowsforaperiodoftimewherethekidneyandeararefreefromdrugexposure.As
well,nephrotoxicitywithaminoglycosidesisnotanacuteeventandisassociatedwithduration
longerthan7days.Therefore,becauseofthehighresistanceratestofluoroquinolonesand
lowriskofnephrotoxicitywithappropriatedosingandshortcoursesof
aminoglycosides,patientswithIgEmediatedorotherseverereactionstobetalactam
antibioticsshouldbetreatedwithgentamicinandmetronidazole

ReviewerComment:MyonlycautionwouldbeontheuseofgentamicinasthealternativetoAncefin
Penallergicpeople.Iknowitsagreatantimicrobialbutsomanyofushaveessentiallystoppedusingit
becauseoftoxicityreasons.Again,althoughit'srareifusedproperly,thefactisitgetsblamedforany
renaltoxicityregardlessofitbeinganinnocentbystandermostofthetime.Ihavedoneseveralmedico
legalcaseswithGeneralsurgeonsusingGentamicinandgettingintotroublewithrenaltoxicity.
Somethingtoconsider.Eventhoughyoumayonlyneedtogiveoneortwodoses,thesethingshavea
wayofbeingusedforlongerandchangingpractisewillbeaworkinprogress.
AuthorsResponse:Wewillundertakeeducationinterventionstofamiliarizeclinicianswiththecurrent
evidenceandhopefullyensuregentamicinisusedappropriatelyandfortherecommendedduration.

ReviewerComment:SelectionofempiricantimicrobialagentsLastbulletnotsurefluconazoleis
alwaysindicated,mayconsiderchangingthewordshouldtoshouldconsider.
AuthorsResponse:Agreewithcomment.Changesmade:PatientswithhealthcareassociatedIAI
shouldreceiveantifungaltherapyifyeastareidentifiedinperitonealsamples.Fluconazoleshouldbe
consideredastheempiricagentofchoiceinthemajorityofpatients.Patientswithcommunityacquired
IAIlikelydonotrequireantifungaltherapy.

ReviewerComment:Isthereanyobjectivecriteriatodistinguishbetweenthosepatientswhoshould
havecoveragebroadenedwithCeftriaxonevsthosethatcanbetreatedwithcefazolin(with
metronidazoleforboth)?
AuthorsResponse:Agreewithcomment.Changesmade.SeeDefinitionsSection

ReviewerComment:Whenyousuggestacarbapenem,alsoaddertapenem.
AuthorsResponse:WhenwesuggestaCarbapenum,wearesuggestingitforhospitalacquired
infections.Ertapenemdoesn'thavethecoveragerequired.Ertapenemisanoptionforcommunity
acquiredbutwehaveelectedtokeepthechoiceslimited.

April2011 Page19of26
ReviewerComment:Whendiscussingtheempiriccoverageofenterococcus,dialysisptcouldbean
exception.
AuthorsResponse:Agreewithcomment.Changesmade.SeeDefinitionsSection

ReviewerComment:Thereisnocommentaboutsourcecontrolforpancreatitisthisdoesnotalignwith
theotherprocesseswheresourcecontrolisalwaysmentioned.MightrefertotheNEJMpaper2010,
alsoMierAJSpaper.
AuthorsResponse:Managementofacutepancreatitisisoutsidethescopeofthisguideline.

ReviewerComment:Recommendation#5bullet2:Clarifythatsourcecontrolforcholecystitisis
cholecystectomy
AuthorsResponse:Agreewithcomment.Changesmade.

ReviewerComment:Insection2defineinrecommendationspoint2whatareyouspecificallylooking
forwhenclinicalsignsofinfectionhaveimprovednofeverx24hrs?nofeverx48hrs?noWBC?
AuthorsResponse:Agreewithcommentchangesmade.

ReviewerComment:Aretheredatatosupporta5daycourseofIVtransitiontooralmeds(supported
byareference)?
AuthorsResponse:Inthesepatients,atotalofa5daycourse(withatransitiontooral)isreasonable.A
prolongedcourseofantimicrobials(>7days)shouldbeavoidedunlesssourcecontrolisincomplete.
Evidence:JGastrointestSurg.2008Mar;12(3):592600.Epub2007Sep11.Aprospective,doubleblind,
multicenter,randomizedtrialcomparingertapenem3vs>or=5daysincommunityacquired
intraabdominalinfection.BasoliA,ChirlettiP,CirinoE,D'OvidioNG,DogliettoGB,GiglioD,GiuliniSM,
MaliziaA,TaffurelliM,PetrovicJ,EcariM;ItalianStudyGroupandPediatrSurgInt.2004Dec;20(11
12):83845.Epub2004Oct6.Minimumpostoperativeantibioticdurationinadvancedappendicitisin
children:areview.SnellingCM,PoenaruD,DroverJW.

ReviewerComment:Intermsoflocalizedabscessesmostofuswoulduseantibioticsfor14days,even
whenadrainisplaced.
AuthorsResponse:Theevidencedoesnotsupportaprolongedcourseofantibiotics.Thus,thischange
hasnotbeenmade.

ReviewerComment:Therecommendationtostartantibioticsshouldprobablyputmoreemphasison
startingantibioticsrapidly.TheSurvivingSepsisCampaignhasreviewedthis,andrecommendsthat
antibioticsbestartedwithinanhourofdiagnosisforpatientswithseveresepsisorsepticshock.Since
obtainingculturesisnotusuallyanissueinintraabdominalinfection,earlyinitiationshouldbereadily
accomplished.
AuthorsResponse:Agreewiththissuggestioninpatientswithseveresepsis.SeeSummaryof
EvidenceunderRecommendation#2.Forpatientswithseveresepsis(associatedwithhypotensionor
neworganfailure),thereissomeevidencetosuggestthatdelayininitiatingantimicrobialtherapy
increasesmortality.

ReviewerComment:ThesecondparagraphtalksaboutantibioticuseinspecifictypesofIAIandcallsit
"prophylactic".IthinkthatitisunwisetolabeltheseasprophylacticasthereisIAIandtheyareclearly
differentfromtrueelectiveantimicrobial.Ithinkitmightbeabetterideatoaddressthisinthecontext
ofthedurationoftherapyindicatingthattherearespecificcircumstanceswheredurationmightbevery
short(ielikeprophylaxis)duetothefactthattheorganisremoved,orthebacterialloadissmalletc.

April2011 Page20of26
AuthorsResponse:Agreewithcomment.Insteadofusingprophylaxis,thetermultrashortcourseis
used.Seechangesinpreamble:Itisimportanttodistinguishtheantimicrobialtreatmentrequiredfor
complicatedIAIsfromtheultrashortcourseofantibiotictherapyrequiredinuncomplicatedIAI(suchas
nonperforatedappendicitisorsimplecholecystitis).

ReviewerComment:Ifstaphaureusisgrowninblood,IVantibioticsareneededforatleast14days.
AuthorsResponse:Agreewithcomment.Changesmade:AnInfectiousDiseaseconsultshouldbe
obtainedonpatientswithenterococcalorstaphylococcusaureusbacteremiaasthereisapotentialfor
metastaticinfectionin.Thesepatientstypicallyrequirelongercoursesofantimicrobialtherapy.
ReviewerComment:Onpage6,thirdlinefrombottom,Iwouldsuggestremoving"freeair".Thereare
circumstanceswheretherecanbefreeairbutlocalizedinfectionandPCDmightbeindicated.
(appendicaealordiverticularabscess).YoumightalsoindicatethatPCDisnotindicatedintheveryearly
postopperiodwheretheremightbeadominantfluidcollectionseenonscanwithalittleelsewhere
exampleiscysticductleakorinadvertantenterotomy.
AuthorsResponse:Agreewithcomment.Changesmade.

ReviewerComment:Becarefulwhendiscussinganaerobicculturesthelabcandotheseifsterile
samplesplacedinbloodculturebottlesbutarenotabletodothisfromswabs.
AuthorsResponse:Peritonealfluidshouldbesenttothelabinaerobicandanaerobicbloodculture
bottles.

ReviewerComment:Recommendation3,page5,Peritonealsamplesshouldbeobtainedinallpatients
withhealthcareassociatedIAI...isastrongrecommendation,andshouldbesupportedinthe
literature.
AuthorsResponse:Thereisnoevidenceforthis.Mostwouldagreethatthisisnecessarytotailor
therapypostop.thebugsaremuchlesspredictableinthesepatients,hencetheneedforcultures.

ReviewerComment:Recommendation#3bullet4:addbloodculturestoaerobicandanaerobicbottles,
i.e.aerobicandanaerobicbloodculturebottles.
AuthorsResponse:Agreewithcomment.Changesmade.

ReviewerComment:Recommendation6,page6,Patientswithlessseveresepsismightbesafely
managed...,couldberestatedtosuggestthatthereisanoptiontomanagethesepatientswith
primaryanastomosis.
AuthorsResponse:Webelievethatthestatementasitiswrittenaddressesthisissue.Thereiscurrently
insufficientevidencetomakearecommendationaboutprimarycolonicanastomosisversusstomainthe
settingofperitonitis.

ReviewerComment:Managementofinfectedpancreaticnecrosishasevolvedsubstantially,andthere
aregoodRCTdatasupportingastagedapproach,withpercutaneousdrainage(evenifincomplete)
followedbyoperativeinterventionifneeded.Itwouldbeworthemphasizingthatdelayedintervention
insuspectedpancreaticinfectionisassociatedwithabetteroutcome,oratleastthatinfected
pancreaticnecrosisisanexceptiontotheotherwisesoundprincipletatsourcecontrolshouldbe
initiatedearly.Analgorithmforthemanagementofinfectedpancreaticnecrosisisprobablybeyondthe
scopeoftherecommendations.
AuthorsResponse:Managementofpancreatitisisoutsidethescopeofthisguideline.

April2011 Page21of26
ReviewerComment:Pyogenicliverabscessmaynotbeabletotargetculturedorganismalonebut
widentoincludeentericpathogensincludinganaerobes.
AuthorsResponse:Pyogenicliverabscessisoutsidethescopeofthisguideline.

ReviewerComment:Canyouindicateinyourguidelinestheagelimitsuponwhichtheseguidelinesare
based?Thequestionisapplicabilityoftheseguidelinestopediatricorinfantpopulationsweseehereat
SickKids.PerforatedNECisthemostcommonabdominalsepsisinfantpopulationweseewithaneed
forclearantimicrobialguidelines(coverageanddurationoftherapy)andtheperforatedappendicitis
populationisthemostcommonpediatricpopulationweseeinneedofclearantimicrobialguidelines.
Whiletheseguidelinesmaynotapplytoourinfantpopulation,weprobablycanadopttheseforthe
olderkidswithcommunityacquiredperfdappysandIwouldbethrilledifwehaveevidenceto
showthatcefazolin+metronidazoleorceftriaxone+metronidazoleispreferabletoourcurrent
amp/gent/metrionidazoletreatment.
AuthorsResponse:PerforatedNECexceedstheextentofthisguideline.

ReviewerComment:Usepluralswhendataused.
AuthorsResponse:Agreewithcomment.Changesmade.

ReviewerComment:SpelloutPiptaz,page10.
AuthorsResponse:Agreewithcomment.Changesmade.

ReviewerComment:Page9lastparagraph,3rdline:"coliformbacteriaarethemostcommonorganisms
iftheirsourceistheGItract,".
AuthorsResponse:Agreewithcomment.Changesmade.

ReviewerComment:p9ref26shouldthisberef27
AuthorsResponse:Agreewithcomment.Changesmade.

ReviewerComment:Itneedstobemore"readable"ingeneral.Formostpeople,seeingamultipage
documentlikethismayputthemoffreadingit.Istheresomewayitcouldbeformatteddifferentlywith
almostan"ExecutiveSummary",sotospeak,rightatthebeginninggivingthehighlightsofeach
categoryofrecommendation.
AuthorsResponse:Agreewithcomment.SeechangestoPreambleincludingSummaryof
Recommendations.ThefullguidelinewillbeavailableontheBPIGSwebsite.Inaddition,asummary
oftherecommendationswillbemadeavailableoncardsandfordownloadfromthewebsite.

ReviewerComment:Iwouldsuggestthattherebeabriefsummarywithbulletedrecommendations
thatcanbeeasilydownloadedontoaPDA.
AuthorsResponse:Agreewithcomment.SeeSummaryofRecommendations

ReviewerComment:Recommendation#5allbullet:reorganizebulletsbybiliaryinfectiontypesoeasier
toread
AuthorsResponse:Agreewithcomment.Changesmade.

ReviewerComment:Recommendation#2bullet:moveappendicitiscommentcurrentlyin
Recommendation#2bullet2tobullet3sothatdurationoftherapycommentsalltogether.
AuthorsResponse:Agreewithcomment.Changesmade.

April2011 Page22of26
ReviewerComment:Adddefinitionsatbeginningofdocumentinaneasytofindlocation,e.g.
complicatedIAI,mildmoderateIAI,highseverityIAI.
AuthorsResponse:Agreewithcomment.Changesmade.SeeDefinitionSection.

ReviewerComment:IsthedefinitionofmildtomoderateinfectionregardingIAIwidelyaccepted?
AuthorsResponse:Agreewithcomment.Changesmade.SeeDefinitionSection.

ReviewerComment:Recommendation#5bullet3:definemildmodseverity.
AuthorsResponse:Agreewithcomment.Changesmade.SeeDefinitionSection.

ReviewerComment:Thetermhealthcareassociatedmayneedtobedefinedinmoredetail.
AuthorsResponse:Agreewithcomment.Changesmade.SeeDefinitionSection.

ReviewerComment:IhaddifficultywithfollowingtheguidelineinSection1.Ithinkearlydefinitions
andexamplesofMildtomoderatecommunityacquiredIAIandHighseveritycommunityacquiredIAI.
Atablemightbeaquickandeasywaytodescribethisinformationforsection1andforbiliarysepsis.
AuthorsResponse:Agreewithcomment.Changesmade.SeeDefinitionSection.

ReviewerComment:UsecIAItorefertocomplicatedIAIRecommendations#1bulletonereferstoIAI
withoutmentionofcomplicated;Recommendation#2bullet1referstoitascomplicatedIAIwhich
suggeststhattheserecommendationsarenotbothreferringtocIAI.
AuthorsResponse:Agreewithcomment.Changesmade.

April2011 Page23of26
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