Intra-abdominal Infection in Adults - Management of Complicated

Publication: 09/11/2009  
Last review: 20/09/2017  
Next review: 01/09/2020  
Clinical Guideline
CURRENT 
ID: 1427 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Update on aztreonam injection shortage - now only restricted outside of CF and UTI (protected antibiotic codes no longer required for these indications). See alternatives - 22 August 2018

Management of Complicated Intra-abdominal Infection in Adults

This guideline

Summary
Intra-abdominal Infection in Adults

Definition

  • Complicated intra-abdominal infection is defined as infection that extends beyond the hollow viscus of origin into the peritoneal space and is associated with either abscess formation or peritonitis.
  • Complicated intra-abdominal infection includes patients who have infection post intra-abdominal surgery.

History and examination

  • Routine history, physical examination, and laboratory studies will identify most patients with suspected complicated intra-abdominal infection.

Key diagnostic criteria

  • Features consistent with complicated intra-abdominal infection include:
    • Pyrexia (>37.70C), tachycardia and tachypnoea
    • Abdominal pain and tenderness
    • Confusion or drowsiness
    • Gastrointestinal dysfunction e.g. nausea and vomiting
    • Hypotension

Key assessments

  • An assessment of disease severity should be made.
    • Patients should be assessed for the presence of SIRS (systemic inflammatory response syndrome) criteria and for severe sepsis.
  • An assessment of the risk of treatment failure due to antimicrobial resistance should be made by considering if there is evidence of:
    • Failing to improve on current antibiotic regime
    • History of infection/colonisation with resistant organisms
  • An assessment of possible other sources of infection should be made.
  • An assessment of the risk of Clostridium difficile infection. Risks include age >65 years and severe underlying illness.

Investigations required

  • Investigations should be directed by the clinical presentation and may include
    • FBC, U&E and LFTs
    • Blood cultures
    • ABGs
    • Radiology e.g. Ultrasound scan/CT scan.
    • Microbiology e.g. Intra-abdominal pus.

Non-Antimicrobial Management

Empirical Antimicrobial treatment

Complicated intra-abdominal infection with:

  • Disease severity: No sepsis, sepsis or severe sepsis.
    And
  • Risk of treatment failure: None identified
    And
  • Other sources of infection: None
  • If the patient’s illness is sufficiently severe that they will be transferred to an augmented care unit, i.e. intensive care or high dependency unit, please contact a microbiologist to discuss the antibiotic regime.

Table 1: Antibiotic recommendations for complicated intra-abdominal infection with no other possible source of infection and no identified risk of treatment failure.

Sepsis assessment

No penicillin allergy

Penicillin allergy

<65

>65 or CDI risk1

<65

>65

Sepsis or No sepsis

Cefuroxime electronic Medicines Compendium information on Cefuroxime+ Metronidazole electronic Medicines Compendium information on Metronidazole

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

1st line Linezolid electronic Medicines Compendium information on 

Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly
or 2nd line Teicoplanin electronic Medicines Compendium information on 

Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

1st line Linezolid electronic Medicines Compendium information on 

Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly
or 2nd line Teicoplanin electronic Medicines Compendium information on 

Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

Severe sepsis (pending discussion with microbiology)

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

1st line Linezolid electronic Medicines Compendium information on 

Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly
or 2nd line Teicoplanin electronic Medicines Compendium information on 

Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

1st line Linezolid electronic Medicines Compendium information on 

Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly
or 2nd line Teicoplanin electronic Medicines Compendium information on 

Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

1 Where there is a risk of C. difficile (e.g. > 65 years old) avoid Cephalosporins, Co-amoxiclav and Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin if possible.

#Linezolid electronic Medicines Compendium information on 

Linezolid has a number of drug interactions/contraindications. Please see full guidance (link) to check suitability for the patient. This is an off-label use of Linezolid electronic Medicines Compendium information on 

Linezolid and Teicoplanin electronic Medicines Compendium information on 

Teicoplanin; the patient should be informed of this.

Antimicrobial dosing

Table 4: Antimicrobial dosings for recommended drugs.

Drug

Dose

Cefuroxime electronic Medicines Compendium information on Cefuroxime

IV 1.5g 8 hourly

Clarithromycin electronic Medicines Compendium information on Clarithromycin

PO 500mg 12 hourly

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin

IV 400mg 12 hourly or PO 500mg 12 hourly

Gentamicin line lock

10mg/ml.  No. of ml= to fill the volume of the line.

Linezolid electronic Medicines Compendium information on 

Linezolid

PO/IV 600mg 12-hourly

Metronidazole electronic Medicines Compendium information on Metronidazole

IV 500mg 8 hourly or PO 400mg 8-hourly

Teicoplanin electronic Medicines Compendium information on 

Teicoplanin

See dosing guideline

Duration of treatment

  • Antimicrobial therapy should be limited to 4–7 days, unless it is difficult to achieve adequate source control.

Back to top

Background

Background1

  • This guideline applies to the management of adult patients with suspected complicated intra-abdominal infection.
  • Complicated intra-abdominal infection is defined as infection that extends beyond the hollow viscus of origin into the peritoneal space and is associated with either abscess formation or peritonitis [C].
  • Where the underlying condition is appendicitis, cholangitis/cholecystitis, diverticulitis or spontaneous bacterial peritonitis please refer to the relevant guidelines.

Back to top

Clinical Diagnosis

Diagnosis1

  • Routine history, physical examination, and laboratory studies will identify most patients with suspected complicated intra-abdominal infection for whom further evaluation and management is warranted [B].
  • Features consistent with complicated intra-abdominal infection include [B]:
    • Pyrexia, tachycardia and tachypnoea
    • Abdominal pain and tenderness
    • Confusion or drowsiness
    • Gastrointestinal dysfunction e.g. nausea, vomiting, tachycardia, hypotension
  • An assessment of disease severity should be made [D].
    • Patients should be assessed for the presence of sepsis (Infection +SIRS (systemic inflammatory response syndrome) criteria and for severe sepsis.
      • Sepsis= SIRS thought to be cause by an infection
        SIRS= ≥2 of: Body temperature < 36 °C or > 38 °C , Heart rate > 90 bpm, respiratory rate > 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg (4.3 kPa) White blood cell count < 4 × 109 or > 12 × 109 cells/L.
      • Severe sepsis definition: Sepsis + organ dysfunction e.g. hypotension, poor urine output, hypoxaemia, metabolic acidosis, clotting abnormalities or new confusion/altered mental status.
  • An assessment of the risk of treatment failureshould be made [D].
    • Failing to improve on current antibiotic regime
    • History of infection/colonisation with resistant organisms
  • An assessment of possible other sources of infection should be made [D]:
    • Patients who may have complicated intra-abdominal infection may have other possible sources of infection.
    • Identifying other possible sources of infection is important as this will change the investigations completed, antibiotics administered and duration of antibiotics.
    • Common possible other source of infection include pneumonia (community acquired, hospital acquired and ventilator associated), urinary tract infection (UTI or Catheter Associated UTI (CAUTI), surgical wound infection or Central Venous Access (CVC) infection.
    • Patients with intra-abdominal sepsis only often have symptoms of other sites of infection e.g. shortness of breath and urinary frequency.

Back to top

Investigation

Investigation1

  • FBC, U&Es, LFTs, clotting profile (INR) and amylase [C]
  • Blood cultures (Please see LTHT guidance for blood culture sampling in adults) [C]
  • Paired blood cultures of Central Venous Catheters if present
  • Urine Dipstick on MSU +/- Mid Stream Urine [C]
    or Catheter Specimen Urine (i.e. no urine dipstick on CSU).
  • CXR
  • Arterial Blood Gas (if evidence of acute abdomen, organ failure or sepsis) including lactate[D]
  • Pregnancy test (if applicable) [C]
  • Abdominal X-Ray [C]
  • Further imaging depending on clinical findings and suspected diagnosis (e.g. USS, CT) [C]
  • If biliary infection is suspected ultrasound is the primary imaging technique [C].
  • For other causes of suspected complicated intra-abdominal infection CT scans are normally the test of choice [C].
  • Microbiological culture and sensitivity testing of intra-abdominal fluid should be completed when possible. Urgent Gram stains are not routinely completed as the empirical antimicrobial therapies cover all shapes of bacteria that may be seen on the Gram stain [D].

Back to top

Treatment

Treatment1,2,3

Source control [C]
Source control is defined as any single procedure or series of procedures that eliminate infectious foci, control factors that promote ongoing infection, and correct or control anatomic derangements to restore normal physiologic function (i.e. radiological or surgical drainage).

  • An appropriate source control procedure to drain infected foci, control ongoing peritoneal contamination by diversion or resection, and restore anatomic and physiological function to the extent feasible is recommended for nearly all patients with intra-abdominal infection.
  • Patients with diffuse peritonitis should undergo an emergency surgical procedure as soon as is possible, even if ongoing measures to restore physiologic stability need to be continued during the procedure.
  • Where feasible, percutaneous drainage of abscesses and other well-localized fluid collections is preferable to surgical drainage.
  • Highly selected patients with minimal physiological derangement and a well-circumscribed focus of infection, such as a periappendiceal or pericolonic infected tissue, may be treated with antimicrobial therapy alone without a source control procedure, provided that very close clinical follow-up is possible. This strategy is a compromise strategy as drainage/source control is considered the optimal therapy. It may be useful where surgical procedures are unlikely to be successful or where there is an unacceptable risk from the operative procedure.

Source control failure: Where a focus of infection cannot be surgically managed and antibiotic therapy is being relied upon providing cure, consider a microbiology review to see if therapy can be optimised.

Back to top

Non-Antimicrobial Treatment
  • ABC resuscitation (Please see Severe Sepsis Screening Tool and Resuscitation Care Bundle Guideline)
  • Intravenous fluids. These should be considered in all patients with complicated intra-abdominal infection even if severe sepsis is not present.
  • Analgesia - oral or parenteral
  • Senior surgical assessment of disease severity
  • Consider invasive monitoring and level 2 or 3 care if required [C]

Back to top

Empirical Antimicrobial Treatment

Empirical Antimicrobial management [D]

Ensure assessment of the following before reading this section:

  • Disease severity
  • Risk of treatment failure
  • Possible other sources of infection
  • Age of the patient
  • Antibiotic therapy should be reviewed, normally after 48-72 hours, with consideration to the clinical response and microbiological results

With severe sepsis

  • See Severe Sepsis Screening Tool and Resuscitation Care Bundle (Adults)
  • Antibiotics: Please discuss with a Microbiologist
  • If the patient’s illness is sufficiently severe that they will be transferred to an augmented care unit, i.e. intensive care or high dependency unit, please contact a microbiologist to discuss the need for a carbapenem antibiotic.

Timing of antibiotics

  • Severe sepsis: Antibiotics should be administered as soon as possible; There is evidence that outcomes in these patients are adversely affected if antibiotic administration occurs after 1 hour of presentation [B].
  • Sepsis: Antibiotics should be administered as soon as possible.

Complicated intra-abdominal infection with:

  • Disease severity: Sepsis or severe sepsis.
    And
  • Risk of treatment failure: None identified
    And
  • Other sources of infection: None

If the patients illness is sufficiently severe that they will be transferred to an augmented care unit i.e. intensive care or high dependency unit please contact a microbiologist to discuss the antibiotic regime with a microbiologist.

Antifungal therapy [C]

  • C. albicans or other fungi are cultured from ∼20% of patients with acute perforations of the gastrointestinal tract.
  • Even when fungi are recovered, antifungal agents are normally unnecessary in adults.
  • When candida are cultured antifungals may be indicated if the patient has recently received immunosuppressive therapy for neoplasm or has a perforation of a gastric ulcer on acid suppression or malignancy, transplantation, or inflammatory disease or has postoperative or recurrent intra-abdominal infection.
  • Antifungal therapy for patients with severe community acquired or health care–associated infection is recommended if Candida is grown from intra-abdominal cultures.
  • Empirical antifungal therapy
    • Severe sepsis: Anidulafungin IV 200mg Stat on first day then 100mg on second day and every subsequent 24-hours.
    • Non severe sepsis: Fluconazole electronic Medicines Compendium information on Fluconazole 800mg 24-hourly until the species of candida is known. If C. albicans dose at 400mg 24-hourly. See Candida guideline.
  • Antifungal therapy can be directed to a specific antifungal when the species of candida infecting is known.

Anti-MRSA therapy [C]

  • Routine use of antibiotics with MRSA activity is not recommended.
  • Routine use of antibiotics with MRSA activity is not recommended in those colonised with MRSA unless there is evidence of skin and soft tissue infection e.g. surgical wound infection plus intra-abdominal infection or MRSA is detected from another site with infection.
  • Antibiotics with MRSA activity are recommended when
  • MRSA is cultured from abdominal samples
  • The patient is colonised with MRSA and empirical therapy is not leading to a satisfactory clinical response.

MRSA therapies [C]

#Linezolid electronic Medicines Compendium information on 

Linezolid has a number of drug interactions/contraindications. Please see full guidance to check suitability for the patient. This is an off-label use of Linezolid electronic Medicines Compendium information on 

Linezolid and Teicoplanin electronic Medicines Compendium information on 

Teicoplanin; the patient should be informed of this.

Back to top

Directed Antimicrobial Treatment (when microbiology results are known)
Discuss oral switches with microbiology who will review the microbiological results available.

Back to top

Duration of Treatment

Duration of Treatment [A-C]

  • Antimicrobial therapy of established infection should be limited to 4 days after source control (surgical or radiological intervention), unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.4
  • Antibiotics can be stopped before the neutrophil count is normal if the source has been controlled.
  • The CRP has no defined role in deciding when to stop antibiotics in patients with complicated intra-abdominal infection.
  • Where source control is not possible there is limited evidence for the duration of antibiotics. In the first instance the patient should be apyrexial and the neutrophil count should be normal.
  • Source of infection: Not removed and persistent colonic leak.
    Where the source of infection is not removable and there is a persistent leak from the gastrointestinal tract, e.g. anastomotic leak from the bowel, antibiotics may need to be continued. There is a high risk that the patient will develop a complication of antibiotic therapy, e.g. antibiotic resistance, fungal infection or C. difficile infection. These patients should be discussed with a microbiologist who will attempt to ameliorate these complications.
  • Source of infection: Not removed but no ongoing gastrointestinal leak.
    Where the source of infection is not removable but there is not an ongoing colonic leak e.g. intra-abdominal collection not amenable to drainage, antibiotics may need to be continued for a number of weeks. There is no good evidence to support a recommendation for the number of weeks and this will depend upon many factors including the size of the collection. The recommended duration of antibiotics ranges from a minimum of 2 weeks up to 6 weeks.

Back to top

Switch to oral agent(s)

Discuss oral switches with microbiology who will review the microbiological results available.

Back to top

Treatment Failure
  • Patients may take 48-72 hours to become apyrexial so pyrexia after 24 hours should not normally be associated with failure to respond to antibiotics.
  • In patients who are failing to improve on antibiotics consideration should be given to:
    • Failure of source control: If this has not been achieved this is the most likely cause for a patient failing to improve on antibiotics.
    • Wrong diagnosis. An infection requiring alternative therapy may not have been diagnosed e.g. CDI. Or the infection may be extra-intestinal or inflammatory origin requiring alternative antibiotics/treatment.
    • Antibiotic dosing: Is the dose sufficient? For example oral antibiotics, e.g. Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav , may be administered at higher doses intravenously.
    • Antibiotic resistance. Antibiotic resistance occurs to all antibiotics used at LTHT. Consider repeat culture and sensitivity testing. Consider reviewing the patient’s previous microbiology and changing antibiotics with a microbiologist.

Back to top

Provenance

Record: 1427
Objective:

Aims

  • To improve the management of complicated intra-abdominal infection.

Objectives

  • To provide evidence-based recommendations for appropriate investigation of complicated intra-abdominal infection.
  • To provide evidence-based recommendations for appropriate empirical antimicrobial therapy of complicated intra-abdominal infection.
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set-out criteria for referral to specialists.
Clinical condition:

Intra-abdominal Infection of Unknown Cause

Target patient group: Adults
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

References

  1. Solomkin JS. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010 Jan 15;50(2):133-64.
  2. Wong PF. Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults (review). The Cochrane Collaboration 2005.
  3. Dupont H. The empiric treatment of nosocomial intra-abdominal infections. International Journal of Infectious Diseases 2007;11 S1-S6.
  4. Sawyer RG et al. Trial of Short-Course Antimicrobial Therapyfor Intraabdominal Infection. N Engl J Med 2015;372:1996-2005.

Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Appendix

Complicated intra-abdominal infection with

  • Disease severity: Sepsis or No Sepsis
    And
  • Risk of treatment failure: None identified
    And
  • Other sources of infection: Yes, other sources possible

Table 2: Complicated intra-abdominal infection with other possible source of infection with sepsis i.e. NOT severe sepsis and no risk of treatment failure identified.

Possible sources of Infection in addition to intra-abdominal

Additional Investigations

Pathogens in addition to enteric flora

Antibiotic recommendation

No Allergy

Penicillin allergy

<65

>65 or CDI risk1

<65

>65

Intra-abdominal +/-

CAP

CXR See CAP guideline, investigations based on CURB score.

S. pneumoniae H. influenza M. Catarrhalis Atypicals e.g. mycoplasma

Cefuroxime electronic Medicines Compendium information on Cefuroxime+ Metronidazole electronic Medicines Compendium information on Metronidazole +/- Clarithromycin electronic Medicines Compendium information on Clarithromycin *

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam+/- Clarithromycin electronic Medicines Compendium information on Clarithromycin*

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

HAP

CXR +/- Sputum culture

S. pneumoniae H. influenza M. catarrhalis

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

VAP

CXR +/- Sputum culture

S. pneumoniae H. influenza M. catarrhalis Pseudomonas spp

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

UTI

Urine dipstick MSU

 

Cefuroxime electronic Medicines Compendium information on Cefuroxime+ Metronidazole electronic Medicines Compendium information on Metronidazole

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

CAUTI

NO urine dipstick CSU

Pseudomonas spp

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

CVC

Paired blood cultures

MSSA MRSA Skin flora

Consider line removal Gentamicin line lock Cefuroxime electronic Medicines Compendium information on Cefuroxime + Metronidazole electronic Medicines Compendium information on Metronidazole + 1st line Linezolid electronic Medicines Compendium information on Linezolid#  or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin if MRSA colonised

Consider line removal Gentamicin line lock Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam + 1st line Linezolid electronic Medicines Compendium information on Linezolid# or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin if MRSA colonised

Consider line removal Gentamicin line lock

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

Wound

Wound swab

MSSA MRSA S. pyogenes

Cefuroxime electronic Medicines Compendium information on Cefuroxime+ Metronidazole electronic Medicines Compendium information on Metronidazole + 1st line Linezolid electronic Medicines Compendium information on Linezolid#  or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin if MRSA colonised

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam+ 1st line Linezolid electronic Medicines Compendium information on Linezolid#  or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin if MRSA colonised

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

* If clinical suspicion of an atypical pneumonia (e.g. mycoplasma) we suggest adding a macrolide antibiotic e.g. Clarithromycin electronic Medicines Compendium information on Clarithromycin .
CAP: community acquired pneumonia, HAP: hospital acquired pneumonia, VAP: ventilator associated pneumonia, UTI: urinary tract infection, CAUTI: catheter associated urinary tract infection, CVC: central venous catheter.

1 Where there is a risk of C. difficile (e.g. > 65 years old) avoid Cephalosporins, Co-amoxiclav and Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin if possible.

#Linezolid electronic Medicines Compendium information on Linezolid has a number of drug interactions/contraindications. Please see full guidance (link) to check suitability for the patient. This is an off-label use of Linezolid electronic Medicines Compendium information on Linezolid and Teicoplanin electronic Medicines Compendium information on Teicoplanin; the patient should be informed of this.

Complicated intra-abdominal infection with

  • Disease severity: Severe sepsis
    or
  • Risk of treatment failure: Yes, risk of treatment failure identified
    And
  • Other sources of infection: Yes, other sources possible
    • Discuss with a microbiologist
    • Pending discussion with microbiology please refer to table
    • If the patients illness is sufficiently severe that they will be transferred to an augmented care unit i.e. intensive care or high dependency unit please contact a microbiologist to discuss the need for a carbapenem antibiotic with a microbiologist.

Table 3: Complicated intra-abdominal infection with other possible source of infection with severe sepsis or risk of treatment failure identified.

Possible sources of infection in addition to intra-abdominal

Additional investigations

Pathogens in addition to enteric flora

Antibiotic recommendation

No penicillin allergy

Penicillin allergy

Intra-abdominal +/-

CAP

CXR See CAP guideline, investigations based on CURB score.

S. pneumoniae H. influenza M. Catarrhalis Atypicals e.g. mycoplasma

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam+/- Clarithromycin electronic Medicines Compendium information on Clarithromycin *

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

HAP

CXR +/- Sputum culture

S. pneumoniae H. influenza M. catarrhalis

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

VAP

CXR +/- Sputum culture

S. pneumoniae H. influenza M. catarrhalis Pseudomonas spp

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

UTI

Urine dipstick MSU

 

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

CAUTI

NO urine dipstick CSU

Pseudomonas spp

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

CVC

Paired blood cultures

MSSA MRSA Skin flora

Consider line removal Gentamicin line lock Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam + 1st line Linezolid electronic Medicines Compendium information on Linezolid# or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin# if MRSA colonised

Consider line removal Gentamicin line lock

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

 

Wound

Wound swab

MSSA MRSA S. pyogenes

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam+ 1st line Linezolid electronic Medicines Compendium information on Linezolid#  or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin# if MRSA colonised

1st line Linezolid electronic Medicines Compendium information on Linezolid *$ 600mg 12-hourly PO/IV + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin$ IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly

* If clinical suspicion of an atypical pneumonia (e.g. mycoplasma) we suggest adding a macrolide antibiotic e.g. Clarithromycin electronic Medicines Compendium information on Clarithromycin .
CAP: community acquired pneumonia, HAP: hospital acquired pneumonia, VAP: ventilator associated pneumonia, UTI: urinary tract infection, CAUTI: catheter associated urinary tract infection, CVC: central venous catheter.

#Linezolid electronic Medicines Compendium information on Linezolid has a number of drug interactions/contraindications. Please see full guidance to check suitability for the patient. This is an off-label use of Linezolid electronic Medicines Compendium information on Linezolid and Teicoplanin electronic Medicines Compendium information on Teicoplanin; the patient should be informed of this.

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.