Antimicrobial Guidelines in

Abdominal Infection: Recent

Guideline
Learning Issue

• SEPSIS
• EPIDEMIOLOGI
• PENANGANAN
• ABDOMINAL INFECTION
• GUIDELINE
CASE 1
Seorang laki-laki berumur 30 tahun,
dibawa keluarganya ke IGD Rumah Sakit
H Adam Malik dengan keluhan sesak
napas yang dialami sejak 3 hari ini. Batuk
dan deman tidak dijumpa. Pada
pemeriksaa di jumpai TD : 80/40 mmHg,
HR 120 x/menit, RR : 24x/menit
Major types of infection in adult ICUs
80% infections are in the organs

Pneumonia
4% 6%
4% Urinary tract infections

4% 31% Primary bloodstream infections

5% Gastrointestinal infections
Lower respiratory tract infections
(other than pneumonia)

19% Eye, ear, nose and throat infections

Cardiovascular system

27% Other

National Nosocomial Infection Surveillance (NNIS) dataRichards et al. Crit Care Med 1999;27:887–892
 The importance of early
recognition  the earliest
better
SSC 2012

mfda
Crit Care Med 2006 Vol. 34, No. 6
Initial antibiotics as early as possible and no needs dose
adjustment independent of the patient’s renal function

Dellinger RP, Levy MM, Rhodes A, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis a nd septic shock. Crit Care Med 2013; 41(2): 580- 637
Classification of antimicrobials according to their
solubility and pharmacokinetic/pharmacodynamic
properties

Pea F, Viale P: The antimicrobial therapy puzzle: could pharmacokinetic-pharmacodynamic relationships

be helpful in addressing the issue of appropriate pneumonia treatment in critically ill patients? Clin Infect Dis 2006, 42:1764-1771
Clinical scenarios likely to alter antibiotic PK
in Multi Organ Dysfunctions

CHEST 2011; 139( 5 ): 1210 – 1220

EPIDEMIOLOGY
• A recent multi-center observational study, conducted in 132 medical
institutions worldwide mortality in this study was 9.2%
• Mortality from intra-abdominal sepsis depends on severity and
ranges from 7.5% to 43%
• The prevalence of cIAI found in six tertiary hospitals in Indonesia in
mid- 2017 was approximately 10%, with mortality of 16.6%

SURGICAL INFECTIONS Volume 19, Number X, 2018

• Clinical practice guidelines (CPG) were developed in 1992
• As a result of heterogeneity in management, cIAI mortality rates are
high, not just in Indonesia, but worldwide, ranging from 3%– 42%
• Optimal management of abdominal sepsis relies upon several factors,
the most important being prompt resuscitation, timely and efficient
source control, provision of intensive care and administration of
appropriate effective antimicrobials
• Empirical antibiotic agents should be administered
intravenously within an hour
• Empirical antibiotics should be administered in consideration of
epidemiologic surveillance, risk factors, disease severity, and
source of infection

SURGICAL INFECTIONS Volume 19, Number X, 2018

Agents and Regimens that May Be Used for the Initial Empiric Treatment of Extra-biliary
Complicated Intra-abdominal Infection
Recommendations for Empiric Antimicrobial Therapy for Health Care Associated
Complicated Intra-abdominal Infection

Agents and Regimens that May Be Used for the Initial Empiric Treatment of Biliary
Infection in Adults
Definition
Classification
Pathophysiology
Etiology
Risk factors
Assessments Management
Prevalence in six tertiary hospitals in Indonesia in 2017 was approximately 10%, with mortality of 16.6%

Intra-abdominal infection is an infection of intraperitoneal organ(s) with a wide spectrum of clinical

entities, involving clinical condition, extent of anatomic derangement, involved microorganisms, risk
factors, and management

Intra-abdominal infection is classified based on two classified as uncomplicated or complicated. From a

healthcare perspective, intra-abdominal infection is classified as community acquired intraabdominal
infection (CA-IAI) or hospital-acquired intra-abdominal infection (HA- IAI)
Intra-abdominal infection (IAI) describes as peritoneal inflammation in response to microorganisms,
resulting in puru lence in the peritoneal cavity

Primary peritonitis is also known as spontaneous bacterial peritonitis. It is thought to be the result of
bacterial translocation across an intact gut wall

Secondary peritonitis is caused by microbial contam- ination through a perforation, laceration, or necrotic
segment of the GI tract

Tertiary peritonitis represents an infection that is persistent or recurrent at least 48 hours after appropriate
management of primary or secondary peritonitis. It is more common among critically ill or immunocom-
promised patients

Complicated abdominal infections extend beyond the source organ into the peritoneal space. They cause
peritoneal inflammation, and are associated with loca- lized or diffuse peritonitis

Uncomplicated abdominal infections involve intra-mural inflammation of the gastrointestinal (GI) tract
without anatomic disruption
 Source of infection in 4553 patients from 132 hospitals worldwide
Sartelli et al. World Journal of Emergency Surgery (2017) 12:29 Page 17
Sartelli et al. World Journal of Emergency Surgery (2017) 12:29 DOI 10.1186/s13017-017-
0141-6
Intra-abdominal infection (IAI) is an important cause of morbidity and mortality. It is the second
most commonly identified cause of severe sepsis in the intensive care unit (ICU). Recent studies
have associated severe intra-abdominal infection with a significant mortality rate.

Most IAI are a result of processes involving inflammation and perforations of the
gastrointestinal tract, such as appendicitis, peptic ulcer disease, and diverticulitis.
Patients with diffuse peritonitis may be due to spontaneous perforation, post-operative, post-
interventional or post-traumatic causes. The lower GI tract is most often the location of
perforation.
Infectious Diseases in Clinical Practice & Volume 18, Number 3,
May 2010
Empiric therapy of primary peritonitis.
Therapy of mild or moderate secondary peritonitis.Severe secondary peritonitis.
The Word Society of Emergency Surgery guidelines
 Pr, 78 thn, BB:45 kg

• KU : Nyeri Seluruh Lapangan Perut

• Telaah : Hal ini dialami pasien sejak 1 minggu
SMRS. Awalnya pasien mengeluhkan nyeri di sekitar ulu hati
dan tidak hilang dengan meminum obat pereda nyeri. Lalu
nyeri menyebar ke seluruh perut dan memberat 1 hari
sebelum pasien masuk Rumah Sakit. Riw Mual (+) Riw.
Muntah (+) berwarna hijau dan berisi makanan yang di
makan. Riw. BAK (+), Riwayat BAB (-) 3 hari ini.
• RPT : Pemeriksaan Fisik di IGD 10/11/2019
• RPO : Parasetamol

•Airway clear , Snoring,crowing/gargling:-/-/-, Sp : ves , ST : Rh -/- , RR 24x/i SpO2: 95%

•Akral Hangat /merah/Kering , CRT < 2 detik ,TD: 120/80 HR: 101x / menit, T/V cukup
•Sens: CM GCS 15, pupil isokor 3mm/3mm, Reflek. Cahaya +/+
•UOP (+) terpasang kateter urin
•Abdomen membesar simetris, Nyeri tekan (+) seluruh lapangan perut
•Edema (-)
Terapi Di IGD

 Bed rest + Head up 30°

 IVFD NaCl 0,9% 20gtt/i
 Inj. Ceftriaxon 1gr/ 12 jam
 Inj. Ketorolac 30mg/8 jam
 Inj. Omeprazole 40mg/24 jam
 Pasang NGT
 Konsul Tindakan Anestesi
 Persiapan darah durante operasi 2 bag PRC
Follow Up hari 1

 Sistem Respirasi : Airway: clear , terintubasi dengan MV: Spontan RR :18,

PEEP 5, FiO2 :50% Bed rest + Head up
IVFD Asering 20 gtt/menit
 Sistem kardiovaskular : CRT <2 detik, Akral: Hangat/merah/kering, TD:
Inj. Meropenem 1 gr /8 jam/iv
130/80, HR: 88 x/menit T: 36,8 C
Inj. Omeprazol 40 mg / 24 jam iv
 Sistem Neurologi : Sensorium: Somnolen , pupil isokor 3 / 3 mm, RC = +/+ Inj. Fentanyl 300 mcg dalam 50 cc NaCl 0,9%
 titrasi
 Sistem Genitourinari : Urine Output (+), volume 50 cc/jam, warna
Diet TPN  IVFD Clinimix 7gtt/i
kuning
IVFD Clinoleic 7 gtt/i
 Sistem Gastrointestinal : Abdomen soepel, Luka Operasi tertutup verban

 Sistem Dermatomuskuloskeletal : oedem (-)

Follow rawatan hari ke 2

 Sistem Respirasi : Airway: clear , terintubasi dengan MV SIMV 12, Bed rest + Head up
VT 350, PEEP 5, FiO2 40%. Sp: ves, ST: Rh-/-, SatO2 : 99% IVFD Asering 20 gtt/menit
Inj. Meropenem 1 gr /8 jam/iv
 Sistem kardiovaskular : CRT <2 detik, Akral:
Inj. Omeprazol 40 mg / 24 jam iv
Hangat/merah/kering, TD: 99/74, HR: 115 x/menit T: 37,2 C, CVP
Inj. Fentanyl 300 mcg dalam 50 cc NaCl 0,9%  titrasi
: 10,2
Diet TPN  IVFD Clinimix 7gtt/i
 Sistem Neurologi : Sensorium: Apatis, pupil isokor 3 / 3 mm, RC = IVFD Clinoleic 7 gtt/i
+/+ Koreksi Albumin (albumin tanggal 11-11-19 = 1,6)
 Sistem Genitourinari : Urine Output (+), Balance - 200 Inj. Furosemide 5mg/jam
Weaning
 Sistem Gastrointestinal : Abdomen soepel, Luka Operasi tertutup
verban, Drain 200 cc Serohemoragic

 Sistem Dermatomuskuloskeletal: oedem (+)

Follow rawatan hari ke 3
 Sistem Respirasi : Airway: clear , SpO2 : 95%, RR 20x/i, Sp:
Vesikuler, ST -/- Bed rest + Head up
IVFD Asering 20 gtt/menit
 Sistem kardiovaskular : CRT <2 detik, Akral:
Inj. Meropenem 1 gr /8 jam/iv
Hangat/merah/kering, TD: 130/79, HR: 100 x/menit
Inj. Omeprazol 40 mg / 24 jam iv
 Sistem Neurologi : Sensorium: CM, pupil isokor 3 / 3 mm, Inj. Fentanyl 300 mcg dalam 50 cc NaCl 0,9%  titrasi
RC = +/+ Diet TPN  IVFD Clinimix 7gtt/i
IVFD Clinoleic 7 gtt/i
 Sistem Genitourinari : Urine Output (+), 50 cc/jam
Inj. Furosemide 5mg/jam
 Sistem Gastrointestinal : Abdomen soepel, Peristaltik (+) ACC Pindah.
 Sistem Dermatomuskuloskeletal : Oedem (+)