Factors associated with multidrug-resistant bacteria in secondary peritonitis: impact on antibiotic therapy

Progress in medical management of intra-abdominal infection

PURPOSE OF REVIEW

Intra-abdominal infection management remains debated and evidence-based recommendations are often lacking despite numerous studies. These controversies are mainly explained by the limited number of powered and well designed randomized controlled trials. This review focuses on recent studies on antibiotic therapy for intra-abdominal infections and in particular for the management of severe acute pancreatitis.

RECENT FINDINGS

For community-acquired intra-abdominal infection, early source control and antibiotic selection are well codified. In severe forms, every hour of delay between shock and antibiotherapy initiation reduces hospital survival. Antibiotics dose adjustment and continuous intravenous administration are suggested in critically ill patients and for difficult-to-treat pathogens. Shorter antibiotic treatment duration seems to offer similar clinical cure rates compared with prolonged therapy and could reduce emergence of resistance. For multidrug-resistant bacteria, the newly developed agents indications need to be better defined. In severe acute pancreatitis, antibiotic prophylaxis does not prevent necrosis infection nor does it reduce surgery requirement or mortality. Antibiotics should be given on demand. Infectious complications in pancreatitis are not reduced by probiotic prophylaxis and mortality is increased.

SUMMARY

There is a growing evidence to support early, dose-adjusted, antimicrobial therapy in severe intra-abdominal infection, together with shorter treatment duration if source control is achieved. This could reduce emergence of resistance without affecting clinical cure rates. In severe acute necrotizing pancreatitis, antibiotic and probiotic prophylaxis to reduce infection or mortality should be avoided.

Intra-abdominal infections

PURPOSE OF REVIEW

The aim of this article is to outline developments in the three cornerstones of treatment of intra-abdominal infections during critical illness: source control; antimicrobial therapy; and mitigation of deranged immune and coagulation responses.

RECENT FINDINGS

Although adequate source control remains the goal of mechanical management of intra-abdominal infections, neither planned re-laparotomy nor open-abdomen management appears to offer a survival benefit as compared with on-demand re-laparotomy. Novel approaches to restoration of a functional gastrointestinal tract have emerged as alternatives to more invasive surgery. A persistent increase in the prevalence of intra-abdominal infections caused by multidrug resistant pathogens has led researchers to investigate shorter-course antimicrobial therapy and other antibiotic administration strategies with encouraging initial results. Therapy with recombinant human activated protein C should now be considered for patients with severe abdominal sepsis associated with a high risk of death.

SUMMARY

Because randomized controlled trials of intra-abdominal infections involve critically ill patients infrequently, only limited evidence-based recommendations regarding the management of these patients may be drawn. Therapy should focus above all else on timely obtainment of adequate source control, in conjunction with judicious use of antimicrobial therapy dictated by individual patient risk factors for infection with multidrug resistant pathogens.