INTRAABDOMINAL INFECTIONS

Abdella Birhan (Bpharm, Msc)

birhanabdella@gmail.com
 Introduction
• Intraabdominal infections are those contained within
the peritoneal cavity or retroperitoneal space.
• The peritoneal cavity extends from the undersurface of
the diaphragm to the floor of the pelvis and contains
the stomach, small bowel, large bowel, liver, gall-
bladder, and spleen.
• The duodenum, pancreas, kidneys, adrenal glands,
great vessels (aorta and vena cava), and most
mesenteric vascular structures reside in the
retroperitoneum
Peritonitisis
Abscess
 Introduction
• Peritonitis is defined as the acute inflammatory
response of the peritoneal lining to
microorganisms, chemicals, irradiation, or foreign-
body injury
• An abscess is a purulent collection of fluid
separated from surrounding tissue by a wall
consisting of inflammatory cells and adjacent
organs.
– It usually contains necrotic debris, bacteria, and
inflammatory cells.
 Introduction
• Peritonitis may be classified as primary, secondary, or tertiary.
• Primary peritonitis, also called spontaneous bacterial peritonitis,
is an infection of the peritoneal cavity without an evident source
in the abdomen.
– Bacteria may be transported from the bloodstream to the peritoneal
cavity, where the inflammatory process begins.
• In secondary peritonitis, a focal disease process is evident within
the abdomen.
– It may involve perforation of the gastrointestinal (GI) tract (possibly
because of ulceration, ischemia, or obstruction), postoperative
peritonitis, or posttraumatic peritonitis (blunt or penetrating trauma).
• Tertiary peritonitis occurs in critically ill patients and is infection
that persists or recurs at least 48 hours after apparently
adequate management of primary or secondary peritonitis.
 ETIOLOGY
• Primary bacterial peritonitis
Peritoneal dialysis
Cirrhosis with ascites
Nephrotic syndrome
 Secondary Bacterial Peritonitis
• Diverticulitis
• Appendicitis
• Inflammatory bowel diseases
• Salpingitis
• Biliary tract infections
• Necrotizing pancreatitis
• Neoplasms
• Mechanical gastrointestinal obstructions
• Trauma
• Intraoperative events
 Intraabdominal Abcsess
• The causes of intraabdominal abscess overlap those of
peritonitis and, in fact, may occur sequentially or
simultaneously.
• Appendicitis is the most frequent cause of abscess.
• Other potential causes include pancreatitis, diverticulitis,
lesions of the biliary tract, genitourinary tract infections,
perforating tumors in the abdomen, trauma, and leaking
intestinal anastomoses.
 Pathophysiology
• Intraabdominal infection results from bacterial entry into the
peritoneal or retroperitoneal spaces or from bacterial
collections within intraabdominal organs.
• In primary peritonitis, bacteria may enter the abdomen via the
bloodstream or the lymphatic system by transmigration
through:
The bowel wall,
An indwelling peritoneal dialysis catheter,
The fallopian tubes in females.
• Hematogenous bacterial spread (through the bloodstream)
occurs more frequently with tuberculosis peritonitis or
peritonitis associated with cirrhotic ascites.
• When peritonitis results from peritoneal dialysis, skin surface
flora are introduced via the peritoneal catheter
 Pathophysiology
• In secondary peritonitis, bacteria most often enter
the peritoneum or retroperitoneum as a result of
perforation of the GI or female genital tracts
caused by diseases or traumatic injuries.
• Also, peritonitis or abscess may result from
contamination of the peritoneum during a surgical
procedure or following anastomotic leak
 Pathophysiology
• Bacterial dissemination occurs throughout the peritoneal
cavity, resulting in peritonitis.
• The fluid and protein shift into the abdomen (called third-
spacing) may be so dramatic that circulating blood volume is
decreased, which causes decreased cardiac output and
hypovolemic shock.
• Accompanying fever, vomiting, or diarrhea may worsen the
fluid imbalance.
• A reflex sympathetic response, manifested by sweating,
tachycardia, and vasoconstriction, may be evident.
• With an inflamed peritoneum, bacteria and endotoxins are
absorbed easily into the bloodstream (translocation), and this
may result in septic shock.
 Microbiology of Intraabdominal Infection
• Primary bacterial peritonitis:
– Is often caused by a single organism.
– In children: Streptococcus pneumoniae or a group A
Streptococcus.
– When peritonitis occurs in association with cirrhotic
ascites, Escherichia coli is isolated most frequently.
– Other potential pathogens are Hemophilus
pneumoniae, Klebsiella, Pseudomonas, anaerobes,
and S. pneumoniae
– Primary peritonitis may be caused Mycobacterium
tuberculosis.
– Peritonitis in patients undergoing peritoneal dialysis is
caused most often by common skin organisms such as
S. epidermidis, Staphylococcus aureus, streptococci,
and diphtheroids.
– Aerobic gram-negative bacilli may cause infections,
particularly in patients undergoing dialysis during
hospitalization.
– Death from primary peritonitis caused by gram-
negative bacteria occurs much more frequently than
from gram-positive bacteria
• Because of the diverse bacteria present in the GI
tract, secondary intraabdominal infections often
are polymicrobial.
• The mean number of different bacterial species
isolated from infected intraabdominal sites
ranged from 2.9 to 3.7, including an average of
1.3 to 1.6 aerobes and 1.7 to 2.1 anaerobes.
 Bacterial Synergism
• A combination of aerobic and anaerobic organisms appears
to increase the severity of infection.
• Facultative bacteria (such as E. coli) may provide an
environment conducive to the growth of anaerobic bacteria.
• Although many bacteria isolated in mixed infections are
nonpathogenic by themselves, their presence may be
essential for the pathogenicity of the bacterial mixture.
• Facultative bacteria in mixed infections can:
Promote an appropriate environment for anaerobic growth
through oxygen consumption
Produce nutrients necessary for anaerobes
Produce extracellular enzymes that promote tissue invasion by
anaerobes
 CLINICAL PRESENTATION AND DIAGNOSIS
Primary Peritonitis:
Symptoms
• Patient may complain of nausea, vomiting (sometimes with
diarrhea), and abdominal tenderness.
Signs
• Temperature elevated
• Bowel sounds are hypoactive
• Cirrhotic patients may have worsening encephalopathy.
• There may be cloudy dialysate fluid with peritoneal dialysis.
Laboratory Tests
• The white blood cell (WBC) count may be only mildly elevated.
• Ascitic fluid usually contains greater than 300 leukocytes/mm3
• Gram stain
Secondary Peritonitis
Signs and symptoms
• Generalized abdominal pain
• Tachypnea.
• Tachycardia
• Nausea and vomiting.
• Temperature 37.7°C to 38.8°C
• Hypotension and shock
• Decreased urine output due to dehydration
Physical examination
• Voluntary abdominal guarding changing to involuntary guarding and a “board-like
abdomen.”
• Abdominal tenderness and distension.
• Faint bowel sounds that cease over time.
Laboratory tests
• Leukocytosis (15,000–20,000 WBC/mm3 with neutrophils predominating
• Elevated hematocrit and blood urea nitrogen because of dehydration
 Treatment
DESIRED OUTCOME
• Correction of the intraabdominal disease
processes or injuries
• Resolution of infection without major organ
system complications (pulmonary, hepatic,
cardiovascular, or renal failure) or adverse drug
effects
 GENERAL APPROACH
• The treatment of intraabdominal infection most
often requires hospitalization and the
coordinated use of three major modalities:
(a) Prompt drainage of the infected site,
(b) Hemodynamic resuscitation and support of vital
functions, and
(c) Early administration of appropriate antimicrobial
therapy to treat infection not eradicated by
surgery
• With generalized peritonitis, large volumes of
intravenous (IV) fluids are required to restore vascular
volume, to improve cardio-vascular function, and to
maintain adequate tissue perfusion and oxygenation.
• Adequate urine output should be maintained to
ensure adequate resuscitation and proper renal
function.
• Intraabdominal infections often directly involve the GI
tract or disrupt its function (paralytic ileus).
• In the interim, enteral or parenteral nutrition as
indicated facilitates improved immune function and
wound healing to ensure recovery.
 Nonpharmacologic Therapy
Drainage Procedures
• Primary peritonitis is treated with antimicrobials
and rarely requires drainage.
• Secondary peritonitis requires surgical removal of
the inflamed or gangrenous tissue to prevent
further bacterial contamination.
Fluid Therapy
 Pharmacologic Therapy
• An empirical antimicrobial regimen should be started as
soon as the presence of intraabdominal infection is
suspected and before identification of the infecting
organisms is complete.
• Therapy must be initiated based on the likely pathogens,
which vary depending on the site of intraabdominal
infection and the underlying disease process.
• After suppuration has occurred (e.g., an abscess has
formed), a cure by antibiotic therapy alone is difficult to
achieve; antimicrobials may serve to improve the results
with surgery.
 Recommendations
1. Antimicrobial regimens for secondary intraabdominal infec-tions should
cover a broad spectrum of aerobic and anaerobic bacteria from the GI
tract.
2. Single-agent regimens (such as antianaerobic cephalosporins, extended-
spectrum penicillins with β-lactamase inhibitors, or carbapenems) are as
effective as combinations of amino-glycosides or fluoroquinolones with
antianaerobic agents. This is also true for antimicrobial treatment of
acute bacterial contamination from penetrating abdominal trauma.
3. Clindamycin and metronidazole appear to be equivalent in efficacy when
combined with agents effective against aerobic gram-negative bacilli
(e.g., gentamicin or aztreonam).
4. For most patients, antimicrobial treatment can be completed orally with
amoxicillin-clavulanate or the combination of ciprofloxacin and
metronidazole.
5. Five to seven days of antimicrobial treatment are sufficient for most
intraabdominal infections of mild to moderate severity
Mild to Moderate Infections
β-Lactam/β-Lactamase Inhibitor
Ampicillin-sulbactam
Ticarcillin-clavulanate
Carbapenems
Ertapenem
Combination Regimens
Cefazolin or cefuroxime plus
metronidazole
Ciprofloxacin, levofloxacin
moxifloxacin, or gatifloxacin,
plus metronidazole
High-Severity Infections
Piperacillin-tazobactam
Imipenem
Meropenem
3rd or 4th generation cephalosporins
(ceftriaxone, ceftazidime, cefepime) plus
metronidazole
Ciprofloxacin plus
metronidazole
Aztreonam plus metronidazole