Abstract
This article addresses controversial issues in the field of intra-abdominal sepsis with particular attention to major changes in management that have evolved during the past decade. In the area of diagnostics, scanning techniques have revolutionized the ability to detect loculated collections, although many of these techniques are of limited value in the early stages of inflammation. The greatest debate concerns the relative merits of scanning techniques; the author's choice is CT scans with contrast, although ultrasonography is preferred in patients who cannot be transported and is probably preferred for pelvic infections. In the area of therapeutics, virtually all studies seem to show that single-drug treatment is as effective as dual combinations or triple-combination therapy that has been standard practice in the past with the proviso that the drug used has activity versus Enterobacteriaceae and B. fragilis. The role of enterococcus remains enigmatic; this organism was readily discounted as an important pathogen in the great majority of cases 10 years ago, but it has subsequently become a major nosocomial pathogen that now commands newfound respect. P. aeruginosa is also controversial, but most studies show that antipseudomonad treatment is not necessary in the empiric selection of drugs and may not be necessary even when P. aeruginosa is found at infected sites; the corollary to this is that aminoglycosides may no longer be required in the dual drug treatment regimens. There is increasing resistance by B. fragilis and some other species of Bacteroides to some of the drugs considered "standard" in the past, including clindamycin, cefoxitin, and cefotetan; nevertheless, it has been difficult to demonstrate that resistance of these organisms correlates with antibiotic failure. It was demonstrated 20 years ago that elective colon surgery must be accompanied by preoperative antibiotics, and erythromycin plus neomycin has evolved as the regimen of choice according to recommendations of authoritative sources for the past 20 years. Nevertheless, surveys of practicing surgeons indicate that most actually combine this oral preparation with parenteral agents as well. The final controversy concerns percutaneous drainage, which has now become a standard technique for dealing with intra-abdominal abscesses in 50% to 90% of cases. This controversy has sometimes been seen as a territorial battle between surgeons and radiologists, and most cases are clearly the prerogative of one discipline or the other, but many are in a gray zone in which clearly defined indications are not readily available.
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