Intra-Abdominal Infection
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1 Intra-Abdominal Infection Case presentation 4th Sept 2013 Done by : Noor Al-Hakami Pharm D Candidate, KSU
2 Objectives: Intra-abdominal infection (overview) Case presentation Relevant Studies
3 Introduction 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) IAIs are classified as uncomplicated or complicated based on the extent of infection
4 Definitions Uncomplicated intra-abdominal infection: Involves intramural inflammation of the gastrointestinal (GI) tract without anatomic disruption. Complicated intra-abdominal infection : When the infection extends into the peritoneal cavity or another normally sterile region of the abdominal cavity.
5 Classification Complicated IAIs involve: Intra-abdominal abscesses Peritonitis John E, Joseph S. (2009). Intra-Abdominal Infections. Surgical Clinics of North America. 89, p
6 Etiology Perforation of hollow viscus cause) Postoperative peritonitis Ischemic damage of bowel wall (leading Infection of intra-abdominal organs Translocation in nonbacterial peritonitis
7 Pathophysiology Bacterial stimuli lead to an almost uniform activation response. Peritoneal edema Protein- rich peritoneal exudates Dilatation of peritoneal blood vessel resulting in enhanced permeability Transmigration of granulocytes From peritoneal capillaries to mesothelial surface
8 Investigations Microbiological Radiological Abdominal x-ray Ultrasound CT abdomen Invasive investigations in ICU Diagnostic peritoneal lavage Bedside laparoscopy
9 Management Physiological resuscitation Patients with septic shock Patients without evidence of volume depletion Source control Drainage Debridement Definitive Management Systemic antibiotics
10 Systemic antibiotics Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, O Neill PJ, Chow AW, Dellinger EP, Eachempati SR, et al. 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;50:
11 Systemic antibiotics : Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, O Neill PJ, Chow AW, Dellinger EP, Eachempati SR, et al. 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;50:
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13 General information: MM. 41 years old female patient, post sleeve gastrictomy, medically free Chief compliant: Patient admitted to ECC due to gastric leak
14 History of presenting illness: Pt. did gastric band and cholecystectomy before 16 years Before one month she did gastric sleeve, 2weeks after the operation the patient develop fever, nausea and vomiting Gastrografin study: gastric leak
15 Past medical history Obesity Past surgical history 4 C/S Cholecystectomy + gastric band before 16 yea rs Gastric sleeved before one month Family history DM, HTN- father & mother Medication history None
16 Review of syste m: Conscious, alert, ori ented General fatigue Palpitation N/V Pain score: 4/10 Abdomen: feeding tube + drain Vital signs: Temp (axillary): 38.4 RR: 20 HR: 93 BP: 149/84 O2sat: 100%
17 Labs
18 Day 1 (28/7) Subjective: General fatigue, palpitation, N/V, pain (score 4). Objective: Temp (axillary) :38.4 Assessment: Post gastric sleeve complications Gastrografin study: gastric leak
19 Plan: Non-pharmacological: NPO, IV fluid Oral feeding tube Chest x-ray CT guided intra abdominal drain insertion Pharmacological: Enoxaparin 40 mg subcut q24h Esomeprazole 40 mg IV q24h Piperacillin sodium and tazobactam sodium 4.5 g IV q8 h Acetaminophen 1000 mg IV q6h prn if pain or fever. Metoclopramide 10 mg IV q8hr prn if N/V
20 Day4 (31/7) Large Gastroscopy: lots of pus in abdomen and two large leak areas. leak Medications Enoxaparin 40 mg subcut q24h Esomeprazole 40 mg IV/day Acetaminophen 1000mg IVq6h (prn) Metoclopramide 10 mg IV q8hr (prn ) Tazocin 4.5g IV q8h laps Vitals Added: WBC RBC Hgb Temp 37.1 P RR 96 Small leak 20 BP 118/74 Multivitamin and meni ral 10 ml syrup po/ day Ferous sulfat 15mg po BID phytonadione 10 mg IV Morphine sulfate 2mg IV push
21 Day 8 (4/8) Another gastroscopy was done 6 clips were applied Cultures Fluid culture : (drained from JVAC ) Wound culture Fluid culture (Pig tail drain) laps WBC RBC Hgb Moderate growth of stenotrophomonus maltophilia Light growth of Candida albicans MRSA Vitals Temp P RR BP /87 Medications Enoxaparin Esomeprazole Acetaminophen Metoclopramide Tazocin Multivitamin and meni ral Ferous sulfat phytonadione Morphine sulfate
22 Stenotrophomonas maltophilia (Xanthomonas maltophilia) It is a motile, aerobic, glucose non-fermenting, non-sporulating, Gram-negative bacillus. It is primarily In our an opportunistic patient human pathogen, case: causing nosocomial infections Sensitive: in immunocompromised Resistant: or debilitated Levofloxacin patients Amikacin It can Trimethoprime adhere to moist foreign Meropenem surfaces /sulfa and form biofilms Characterized by intrinsic resistance to multiple classes of antibiotics
23 Day 9 (5/8)-14 (10/8) Labs 5/8 Albumin 100ml 20% IV q12h 7/8 Fluconazole 400 mg IV q24h 9/8 Kcl 20 meq elix po q12h Labs Cultur e
24 Day 15 (11/8) Low grade temp Vomiting 2 Abd: soft, no abdominal pain Wounds: greenish discharge Plan: Add: Hydrocortisone and miconazole cream topical bid laps WBC 8.0 Vitals Temp 37.6 Medications Enoxaparin Esomeprazole Acetaminophen Metoclopramide Tazocin Multivitamin and menir al Ferous sulfat Albumin Kcl Added: Hydrocortisone and miconazole cream topical bid Hgb 9.6 P 83 RR 20 BP 154/93
25 Day 17 (13/8) Ct abdomen: still intra abdominal collecti on Plan: Patient need further surgical intervention to make sure this drain is functionin g laps WBC RBC Hgb Blood culture Start trimethoprim and sulfamethoxazole Fluid culture No growth Candida glabrata Vitals Temp P RR BP /88 Medications Enoxaparin Esomeprazole Acetaminophen Metoclopramide Tazocin Multivitamin and meni ral Ferous sulfat Albumin Kcl Hydrocortisone and miconazole 14/8 Fluconazole 400 Added: mg (13/8)Trimethoprim and sulfamethoxazole 350 mg IV q12h
26 Day 26 (22/8) Generalized maculopapular rash Blood, urine, respiratory cultures: No gro wth Fluid culture: light growth of Candida gla brata Plan: D/C: tazocin and septrin Add: Tigecycline 50 mg q12h laps Ciprofloxacin 400 mg IV q12h Vitals WBC RBC Hgb 2.8 3,6 9.5 Temp P RR BP Sulfa allergy? /84 Medications Enoxaparin Esomeprazole Acetaminophen Metoclopramide Multivitamin and menir al Ferous sulfat Albumin Fluconazole Kcl Hydrocortisone and miconazole D/C: Tazocin Septrin Added: Tigecycline 50 mg IV q12 h Ciprofloxacin 400 mg IV q12h
27 Day 28 (24/8) Rash increased all over the body Febrile and itchy Plan: D/C fluconazole Add: Why? Caspofungin 50 mg IV daily Promethazine hydrochloride 25 mg IM daily mometasone furoate cream topically daily Enoxaparin Esomeprazole Acetaminophen Metoclopramide Multivitamin and menir al Ferous sulfat Albumin Kcl Hydrocortisone and mico nazole Tigecycline Ciprofloxacin laps WBC 3.3 Vitals Temp 39.5 D/C: Fluconazole RBC Hgb P RR BP /74 Added: Caspofungin 50 mg IV dai ly Promethazine hydrochlori de 25 mg IM daily mometasone furoate cream topically daily
28 Day 38 (3/9) Pt. is stable Rash improved Last culture (23/8): Candida glabrata Last Abd CT (24/8): mild reduction in abdominal collection. Plan: Continue Abx laps No labs Vitals Temp P RR BP /87 Esomeprazole 40 mg IV q12h Acetaminophen 1000 mg IV q6h prn Granisetron hudrochlori de 1 mg IV q12 Multivitamin and menir al 10 ml po daily Ferous sulfat 15 mg po bid Hydrocortisone and mico nazole Cream topical bid mometasone furoate Cream topical daily Emollient Cream topical daily Mirtazapine 7.5 mg tab po daily Tigecycline 50 mg IV q12h Ciprofloxacin 400 mg IV q12h Caspofungin 50 mg IV q24h
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