MEDICAL MANAGEMENT

INTRAVENOUS ANTI MICROBIAL AGENTS

1. Use piperacillin-tazobactam for empiric therapy

2. Consider the use of ceftolozane-tabactam plus metronidazole as an option for empiric therapy
3. Consider use of aztreonam plus metronidazole and vancomycin as an option for empiric therapy
4. Use moxifloxacin for empiric therapy of lower-risk adults, but use with caution in areas where
there is a high incidence of fluroquinolone-resistant Escherichia coli.
5. Use metronidazole as preferred anti anaerobic agent in combination regimens for empiric
therapy.

Complicated IAIs:  As described previously, cIAIs extend beyond the

hollow viscus of origin and into the abdominal cavity with either abscess
formation or peritonitis development. This type of infection requires
source control plus antibiotic therapies (TABLE 2). 3 Empirical antibiotic
treatment is determined based on whether the infection is community-
or healthcare-acquired, in addition to the severity of infection. According
to the IDSA guidelines, empirical broad-spectrum therapy for mild-to-
moderate community-acquired cIAI is recommended. However,
antipseudomonal, enterococcal, and antifungal agents are not warranted
in this subset of patients.3 Nonetheless, the authors caution the use of
ampicillin-sulbactam, cefotetan, and clindamycin secondary to its
increased resistance. In high-risk community-acquired cIAI, broad-
spectrum antibiotics should also be used, either as a single agent or in
combination with metronidazole (TABLE 2). The quinolones should only
be chosen if the local susceptibilities show >90% sensitivity to E
coli.3 Double coverage against gram-negative organisms is unnecessary,
unless a resistant organism is suspected. Additionally, MRSA and fungal
coverage are not required unless cultures are positive for those
organisms.
Resistant organisms are typically present in healthcare-acquired cIAI;
thus, empirical antimicrobial coverage should target those microbiologic
patterns at the local level. Coverage with an antifungal agent should be
initiated if cultures are positive. In Candida albicans infections,
fluconazole is the agent of choice, while an echinocandin is preferred if
resistance develops.3 Empirical coverage for enterococci is
recommended, especially in patients who are immunocompromised or
have valvular heart disease or prosthetic intravascular
devices.3 Vancomycin is the agent of choice in patients who have a
history of MRSA or are colonizers.3

Duration of Therapy:  The antimicrobial therapy duration for cIAIs should

be 4 to 7 days, unless there is inadequate source control. 3 Nonetheless,
treatment duration of 10 to 14 days continues to be widely practiced by
clinicians.17 A recently conducted study evaluated 518 patients, with a
primary goal of determining the optimal duration of therapy. 17 The
study’s control group consisted of 260 patients with cIAI having
adequate source control. These patients received antibiotics until 2 days
after resolution of infection for a maximum of 10 days of therapy. On the
other hand, the experimental group consisted of 257 patients and was
limited to a fixed course of 41 days of antibiotic therapy. One patient
withdrew consent after randomization. It was discovered that the
primary outcomes of surgical site infection, recurrent IAI, or death were
similar among both groups; occurring 21.8% (n = 56) in the experimental
group and 22.3% (n = 58) in the control group (P = .92).17 However, the
sample size to show equivalence was not obtained; therefore, it cannot
be statistically concluded that the groups are equivalent. More trials are
needed to properly determine a fixed duration.