Guidelines for antimicrobial therapy of intra-abdominal
infections in adults
Infectious Diseases Society of Taiwan; Taiwan Surgical Society of Gastroenterology; Medical Foundation in Memory of Dr. Deh-Lin Cheng; Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education; CY Lee’s Research Foundation for Pediatric Infectious Diseases and Vaccines Intra-abdominal infections are important in daily clini- Research Foundation for Pediatric Infectious Diseases cal practice. Outcomes are heavily influenced by timely, and Vaccines.* Three principles are maintained in es- accurate diagnoses and appropriate surgical and radio- logical intervention and by the timeliness and efficacy of antimicrobial therapy. Selection of antimicrobial 1. Guidelines are based on local epidemiology and agents is not only a choice between old versus new or susceptibility patterns of pathogens.
single-agent versus combination therapy, but depends 2. Antimicrobial agents recommended in the guide- on the clinical status of patients, spectrum of activity, lines are agents already marketed in Taiwan.
timing and duration of therapy, dose and dosing fre- 3. Guidelines are based on academic principles rather quency, drug interactions and tolerability, adequacy of than the regulations of the Bureau of National Health drug levels and prior antibiotic treatment. In addition, antimicrobial agents should be used carefully to avoid Special considerations are given to include primary or prevent antimicrobial resistance.
hepatic abscess, mainly due to Klebsiella pneumoniae, A series of symposia was held over the last two and spontaneous bacterial peritonitis due to its high years in order to develop these guidelines. Participants prevalence in Taiwan. Many recommendations are still included experts in the fields of infectious diseases, based on expert opinion and unpublished data, due to a gastroenterology and general surgery.
paucity of well-designed, randomized, controlled clinical A consensus conference for establishing guidelines for antimicrobial therapy for intra-abdominal infec- These guidelines are approved by the board of the tions in Taiwan was held on March 8, 2008 following Infectious Diseases Society of Taiwan, and a copy will a symposium on intra-abdominal infections held in be sent to physicians in all hospitals in Taiwan. These conjunction with the Infections Diseases Society of guidelines are published in the Journal of Microbiology, Taiwan, Taiwan Surgical Society of Gastroenterology, the Immunology and Infection, and are also available at Medical Foundation in Memory of Dr. Deh-Lin Cheng, the Journal’s website ( The guidelines Foundation of Professor Wei-Chuan Hsieh for Infec- will be updated and revised as necessary, to serve as an tious Diseases Research and Education, and CY Lee’s easily accessible reference for all physicians in Taiwan.
Guidelines for antimicrobial therapy of intra-abdominal infections in adults Third-generation cephalosporinsj + metronidazoleg Second-generation cephalosporins (cephamycins)f Cefazolin or cefuroxime + metronidazoleg Piperacillin, piperacillin-tazobactam or ticarcillin- Third- or fourth-generation cephalosporinsh + 2008 Journal of Microbiology, Immunology and Infection Guidelines for antimicrobial therapy of intra-abdominal infections Note: 1. Addition of aminoglycosidesc is optional.
2. The duration of treatment is variable and depends on the type of infection found, adequacy of control of focus, the status of host defenses, and the response to treatment. Patients who have localized peritonitis or an intra-abdominal abscess (if abscess is completely drained) and who are not immunocompromised can be treated for a relatively brief period (7 to 10 days), whereas patients with generalized peritonitis and who are more ill require a longer duration of treatment (10 to 14 days) to 2 to 4 weeks of intravenous therapy followed by prolonged oral antibiotic course (if needed) if drainage is incomplete. Antimicrobial therapy should continue until there are clear signs that the infection has resolved.
3. Continued evidence of infection, e.g., fever, elevated white blood cell count, gastrointestinal tract function, indicates persistent intra-abdominal infection or the occurrence of nosocomial infection at another site. This should prompt appropriate diagnostic investigations.
Surgical intervention and no antimicrobial therapy Second-generation cephalosporins (cephamycins)f Cefazolin or cefuroxime + metronidzoleg Piperacillin, piperacillin-tazobactam or ticarcillin- Third- or fourth-generation cephalosporinsh + Note:1. Addition of aminoglycosidesc is optional.
2. When biliary obstruction is present, even an antimicrobial drug with excellent biliary excretion may not enter the biliary tract.
Cefazolin or second-generation cephalosporinsi As moderate to severe acute cholecystitis/cholangitis - Note: Percutaneous or surgical abscess drainage as early as possible is mandatory.
Cefazolin or second-generation cephalosporinsi aAlternative therapy includes the following considerations: allergy, pharmacology/pharmacokinetics, compliance, costs, and local resistance profiles.
bAdvanced age; poor nutrition; low serum albumin; pre-existing disorders, such as significant cardiovascular disease; higher Acute Physiology And Chronic Health Evaluation II scores (≥15); inadequate source control during the initial operative procedure; resistant nosocomial microorganisms; immunosuppression resulting from medical therapy for transplantation, cancer, or inflammatory disease; or other acute/chronic diseases of difficult-to-define immunosuppression. cGentamicin, netilmicin, amikacin or isepamicin.
dIn a healthy patient with no organ dysfunction and only mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative procedure.
eModerate, any one of the following conditions: 1) elevated white blood cell count (>18,000/mm3); 2) palpable tender mass in right upper quadrant; 3) duration of complaints >72 h; and 4) marked local inflammation (biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis). Severe dysfunction in any of the following organ/systems: 1) cardiovascular dysfunction (hypotension requiring dopamine 5 μg/kg/min, or any dose of dobutamine); 2) neurological dysfunction (decreased level of consciousness); 3) respiratory dysfunction (partial pressure of oxygen/fraction of inspired oxygen ratio <300); 4) renal dysfunction (oligouria, creatinine >2.0 mg/dL); and 5) hepatic dysfunction (prothrombin time/international normalized ratio >1.5); hematological dysfunction (platelet count <100,000/mm3).
2008 Journal of Microbiology, Immunology and Infection Guidelines for antimicrobial therapy of intra-abdominal infections fCefoxitin, cefotetan or cefmetazole.
gOther anti-anaerobic agents include clindamycin or chloramphenicol.
hCefepime or cefpirome.
iCefuroxime, cefoxitin, cefotetan and cefmetazole.
jCefotaxime, ceftriaxone, ceftizoxime or ceftazidime.
* Consensus Conference Participants (in alphabetical order):Yu-Jiun Chan, Feng-Yee Chang, Shan-Chwen Chang, Po-Yen Chen, Tai-An Chen, Yao-Shen Chen, Yee-Chun Chen, Chith-Han Chuang, Yin-Ching Chuang, Wei-Chuan Hsieh, Po-Ren Hsueh, Rey-Heng Hu, Fu-Yuan Huang, Li-Min Huang, Yhu-Chering Huang, Kao-Pin Hwang, Wen-Chien Ko, Yeu-Jun Lau, Chin-Yun Lee, Chun-Ming Lee, Po-Huang Lee, Susan Shin-Jung Lee, Hsieh-Shong Leu, His-Hsun Lin, Ming-Tsan Lin, Tzou-Yien Lin, Cheng-Yi Liu, Ching-Chuan Liu, Jien-Wei Liu, Yung-Ching Liu, Kwen-Tay Luh, Hung-Chin Tsai, Fu-Der Wang, Lih-Shinn Wang, Shue-Ren Wann, Wing-Wai Wong, Muh-Yong Yen, Wen-Lieng Yu 2008 Journal of Microbiology, Immunology and Infection


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