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Intra-Abdominal Infections & C. Difficile Infections

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Acute Cholangitis and CHolecystitis

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6 years ago

Date created

Mar 1, 2020

Cards (46)

Section 1

(46 cards)

Acute Cholangitis and CHolecystitis

Front

Cholecystitis: inflammation of gallbladder Cholangitis: inflammation of bile duct similar treatment approach to IAIs (a specific subset within that blanket term)

Back

Secondary Peritonitis

Front

perforation of the GI tract polymicrobial (perforated appendicitis)

Back

C. Diff Clinical Presentation

Front

-frequent loose water, bowel movements -peripheral leukocytosis often with or without fever -dehydration Lab: -PCR to identify C. Diff toxin in unformed stool (90% sens/sepci for most PCRs) -high WBC bc of toxins

Back

Abscess Formation

Front

neutrophil, tissue factor, activation of coagulation cascade -> contained into a pocker/collection of infected fluid/bacteria fluid collection similar to what you see in Staph skin Abscesses

Back

Keys to Management

Front

Antimicrobial Therapy (1st, most important): -promptly start empiric therapy with coverage against suspected pathogens -consider patient RF Source Control (2nd, crucial): -restore anatomic and physiological function (drain abdominal abcess) -failure or inability to achieve adequate source control associated w/poor clinical outcomes

Back

Piperacillin-Tazobactam Vs Cefepime + Metronidazole

Front

Back

Intra-Abdominal Infections

Front

diverse set of infections usually involving inflammation and/or perforations of GI tract 2nd most common cause of ICU sepsis and mortality (30%)

Back

CA-High Risk or Severe

Front

including severe, physiologic disturbance, advanced age or immunocompromised broader Empiric coverage: -gram neg: bacilli, streptococci, anaerobes, plus pseudomonas and enterococci -adjust based on culture/sensitivity (only use FQ if >90% institutional susceptibility to E.Coli) pt is very sick and needs fluid resuscitation Single Agent: -piperacillin/tazobactam -meropenem -imipenem -doripenem Combination: -ceftazidime or cefepime plus metro -cipro or levo plus metro -aztreonam plus metro (adding gram pos cocci agent like vanco recommended) high risk means cover pseudomonas and enterococcus carbapenems rseved for MDROs (ESBLs)

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Duration of Therapy

Front

limited to 4-7 days (longer if inadequate source control, resistant organisms, immunosuppression, critically ill patients) transition to oral therapy if: -pt tolerates oral diet -micro results if aviailable show susceptibility common oral regimens: -moxi, -cipro or levo plus metro -amox/clav -amox/clav plus cipro source control drives duration of thearpy

Back

Fidaxomicin

Front

-macrocyclic antibiotic that inhibits RNA polymerase -200 mg BID x 10 days targeted against C. Diff unlike metro and vanco effective against sporulation as opposed to metro/vanco which target vegitative cells similar efficacy as vanco but less recurrence expensive (2,800 for 10 day course) mainly used as last line for pts with numerous recurrences (3+)

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Recurrent CDI

Front

recurrent CDI w/i 8 weeks of completion of thearpy repeat metronidazole or vancomycin pulse regimen

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Severe CDI

Front

-albumin < 3/g/dl (plus one more) -WBC > 15,000 -abdominal tenderness vancomycin 125 mg PO QID x 10 days

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Peritonitis

Front

local or diffuse inflammation of peritoneal lining Causes: spontaneous, post operative/interventional/traumatic Pathology: peritoneal cavity holds our IA organs and is filled with ECF (means no bacteria) -> bacterial translocation into this space causes peritonitis -lots of nerve endings in peritoneal space -> lots of stomach pain with infection -Types: primary, secondary, tertiary

Back

CA-Mild/Moderate

Front

Examples: includes perforated or abcessed apendicitis (least severe IAI) Empiric Coverage: -common enteric gram neg bacilli, streptococci & anaerobes -narrower spectrum regimens -no pseudomonal, enterococcus, candida coverage Avoid: -ampicillin/sublactam (high rates of E.Coli resistance) -Clindamycin, Cefotetan (resistance amongst B.Fragilis) Single-Agent Regimens: all have anaerobic coverage, gram neg like E.coli and streptococcus as well -cefoxitin -moxifloxacin -Ticarcillin/CLavulanate -Ertapenem? -Tigecycline? Combination Regimens: if using quinolone have to add metro for anaerobes as well (we dont typically see anaerobes isolated or on cultures but we still treat for them) -cefazolin or Cefuroxime or Cefotaxime or Ceftriaxone plus metronidazole -cipro or levo plus metronidazole

Back

Signs and Symptoms

Front

-abdominal pain -nausea -vomiting -fever abdominal pain due to nerve innervation from inflammatory response many pts ave fever, chills, N/V

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Fluid Analysis and Culture

Front

primary peritonitis w/ascites: (PMN > 250 mm^3 -protein < 1 -glucose > 50 -LDH < 225) -> culture those values -drain abscess and culture fluid -drain abscess for culture if possible or get peritoneal fluid for culture in possible (in cirrhosis) -in pts w/ascites 4L pulled from abdomen typically -> send for culture

Back

Mild/Moderate CDI

Front

diarrhea plus additional signs/sxs not meeting severe/complicated criteria metronidazole 500 mg PO TID x 10 days (alternative vancomycin 125 mg PO QID x 10 days)

Back

C. Difficile

Front

anaerobic spore forming gram + bacillius -produces toxin A and B (highly virulent) -person to person transmission via fecal oral route (big infection issue due to poor hygiene)

Back

Diagnosis/Clinical Presentation

Front

S/Sxs Physical Exam Fluid Analysis and Culture Radiography

Back

C. Diff Pathogenesis

Front

ingest bacteria orally -> travels to lower GI tract (colon) where it acts mainly -> forms spores and vegetative cells -> spores germinate and multiply & sticks to epitherlium then release toxins -> toxins dmg epithelial lining -> microscopic holes in intestine -> watery diarrhea/frequent bowel movements

Back

Newer Therapies

Front

Ceftolozane/Tazobactam (Zerbaxa): Ceftazidime/Avibactam (Avycaz) -both require addition of metronidazole -considered non-inferior to carbapenems -use for mroe resistant pathogens like CRE, but need to add metro for anaerobic coverage

Back

Risk Factors

Front

lead to poor outcomes -degree of peritoneal involvement or diffuse peritonitis -inability to achieve adequate drainage/debridement -delay in initial intervention > 24 hours -high severity of illness -Age > 70 yo (due to not a great immune system and typically numerous commodities) -Comorbidity, degree of organ dysfunction -presence of malignancy -low albumin of malignancy -poor nutritional status

Back

C. DIff Prevalence

Front

-mainly hospital acquired -recurrent infection w/i 30 days in 25% of cases -increased rates of community incidence due to prior abx exposure

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Metro PO vs Vanco PO

Front

Metro: -extensively absorbed in GI -lower colonic concentration -indicated for mild/moderate CDI -cheap -use beyond first recurrent not recommended due to build accumulation and risk of peripheral neuropathy Vancomycin: -poorly absorbed in GI -high intracolonic concentrations -indicated for severe CDI (better than metronidazole) -expensive (especially capsules, can compound PO solution from IV though) -well tolerated -IV vanco does not treat CDI

Back

RF C. DIff

Front

-abx use if the number 1 risk factor (particularly broad spectrum; key culprits clindamycin, third gen ceph, FQs) -proton pump inhibitors -GI surgery/manipulation -prolonged healthcare stay/exposure -serious underlying illness -immunocompromised conditions - older than 65 years old

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Anti-MRSA Therapy

Front

not commonly isolated form patients w/CA-IAI usually give vanco but only if patient develops IAI after recent surgery bc S. Aureus not typically GI pathogen give if: -colonized with MRSA or history of MRSA infection -at risk for infections due to MRSA due to prior treatment fialure or significant abx exposure -post operative infection

Back

Prevalence

Front

# 1 pathogen is E. Coli for IAI for both community and healthcare infections

Back

Tigecycline

Front

tetracycline derivative for: -complicated skin and skin structure infections -community acquired bacterial pneumoniae -complicated intra-abdominal infections can kill people but guidelines still have then as 1st line option (dont want to give to every bc of mortality)

Back

Empiric Abx Coverage

Front

should cover these pathogens Gram Pos: -all pts (streptococci) -at risk: (add enterococci, MRSA) Gram Neg: -all pts (enterobacteriaecae (Klebsiella, E.Coli, Enterobacter spp, Proteus spp)) -at risk: (add P. Aeruginosa) Anaerobes: all pts bacteroides fragilis Fungi: at risk pts candida spp.

Back

IAI Examples

Front

appendicitis diverticulitis peritonitis endocarditis

Back

C. DIff Complications

Front

-pseudomembranous colitis -toxic megacolon -perforations -sepsis -death

Back

Tertiary Peritonitis

Front

persistent or recurrent infection > = 48 hours after appropriate therapy for primary or secondary peritonitis polymicrobial (pseudomonas, MRSA, VRE, Candida Spp.) numerous bugs typically with resistance

Back

Severe & Complicated CDI

Front

any of the following attributable to CDI: -admission to ICU for CDI -hypotension +/- vasopressors -fever > 38 deg C -Ileual or Abdominal Distension -Mental Status changes -WBC > 35k or < 2k -Serum lactate > 2.2 mmol/L -end organ failure (renal failure) vancomycin 500 mg PO QID + Metronidazole 500 mg IV q8h + vancomycin per rectum (500 mg in 500 mL saline as enema) QID

Back

Microflora of GI tract

Front

-Anaerobes: generally in lower colon (bacterioides) -Gram +: strep mainly, sometimes enterococcus -Gram -: enterobacteriaceae mainly Stomach: -streptococcus, lactobacillus -Aerobes 10-100, Anaerobes rare Biliary Tract: -normally sterile (+/- E. Coli, Klebsiella, Enterococci) -Aerobes/Anaerobes 0 Proximal Small Bowel: -Streptococcus, E. Coli, Klebsiella, Lacobacillus, Enterococci -Aerobes 100, few anaerobes Distal Ileum: -E. Coli, Klebsiella, Enterobacter, Enterococci, Bacterioides Fragilis, Peptostreptococci -Aerobes, 100k-10 mil, Anaerobes 1mil -100 mil Colon: -bacterioides spp, peptostreptococci, E. Coli, Klebsiella, Enterococci, enterobacter -aerobes 10^5-10^8, anaerobes 10^9-10^11

Back

HA IAI Types/Coverage

Front

increased risk of infection with MDROs (very similar to severe community) Community Onset: -presence of invasive device at admission -history of MRSA infection or colonization -surgery, hospitalization, dialysis or LTCF resident in previous 12 months Hospital Onset: -positive culture results obtained > 48 hrs after hospital admission (need to have been in hospital for more than 2 days for something else and then show new S/Sxs of IAI) Empiric Coverage: broad spectrum abx -common: enteric gram neg bacilli, streptococci, anaerobes -other: cover pseudomonas, enterococci (consider MRSA, Candida in at risk) adjust regimens based on culture & sensitivity

Back

Diagnosis

Front

Frequent watery diarrhea + C.Diff PCR usually in hosptial and or following recent abx use

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Ertapenem

Front

controversial because its too broad can lead to CRE

Back

Classification (Types)

Front

-focus on complicated because those are typically the ones who need abx Uncomplicated: -contained inside wall of an abdominal organ -inflammation of GI tract without anataomical disruption of GI tract -can progress to complicated IAI -dont always need abx Complicated: extends beyond hollow viscous/organ of origin into peritoneal space --> local (abscess) --> diffuse (primary/secondary/tertiary peritonitis)

Back

Anti-Fungal Therapy

Front

necessary when: -signs of IAI + GI perforation, post op infection -critically ill pts, initial thearpy w/echinocandin recommended (due to increasing rates of non-albicans spp) -pts w/manipulation of GI tract (bc candida lives there normally) -> barrier is compromised and bowel spills after surgery

Back

Physical Exam

Front

-guarding -abdominal tenderness/distention -pain on palpation pts can have guarding (press abdomen -> has rigid response bc of pain, can be tender on pts) guarding happens when abdominal wall tenses to protect inflamed organs underneath involuntarily (can be sign of something severe)

Back

Anti-Enterococcal Therapy

Front

needed for high risk or severe -empiric therapy for E.Faecalis: for HA-IAI, immunocompromised, and postoperative infections -generally dont need for Ca-IAI (enterococcus in 20-30% and generally non-virulent) unless pt is immunocompromised Good Activity: -ampicillin/sublactam -piperacillin/tazobactam -imipenem/cilastatin -vancomycin -tigecycline -linezolid -daptomycin Little to No Activity: -ticarcillin/clavulanate -aztreonam -cephalosporins -meropenem -doripenem -fluroquinolones -aminoglycosides -metronidazole -remember E. Faecium tends to be vanco resistant (mero covers it but imipenem is much better)

Back

CDI Management

Front

-if possible dc offending agent (usually abx) -supportive hydration -DC GI motility agents (loperamide) -stratify pt by disease severity then provide recommended treatment -raise pH to prevent C.Diff from traveling -dont give GI anti motility agents (C Diff toxin in colon and you take Imodium -> you hold onto C.Diff and Toxins -> toxic mega-colon, GI perforation, colitis)

Back

Radiograph

Front

get imaging for these pts -> you want to also drain abscess bc if you dont you minimize pts chances of getting better (source control) abdominal CT with abscess can be seen or peritonitis can be seen

Back

Abx Induced CDI Index

Front

0 = tetracyclines 1 = PCNs, Sulfas, Macrolides 2 = cephalosporins, monobactams, carbapenems, quinolones 3= clindamycin

Back

IAI Etiology

Front

caused by microorganisms in normally sterile spaces or in places they are not typically found -spontaneous -post operative -post traumatic

Back

Primary Peritonitis

Front

no obvious abdominal source or GI tract perforation (caused by bacterial translocation) monomicrobial (Spontaneous bacterial peritonitis SBP) most common kind (complication of cirrhosis where bacteria comes spontaneously out of intestine -> abdominal pain & infection)

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