Intraabdominal Infections Resat Ozaras, MD, Prof. Infection Dept.

Peritonitis Inraabdominal abscess Liver and biliary system inf. Pancreas infections Splenic inf. Appendicitis and diverticulitis

Approach Abd. pain, fever, tenderness, leukocytosis intraabdominal inf.? History and PE Surgery consultation Emprical Tx Culture (blood, peritoneal fluidı...) + other studies

Peritonitis Primary peritonitis Secondary peritonitis Tertiary peritonitis

Primary peritonitis 1. Spontaneous peritonitis in children (<1-2%) postnecrotic cirrhosis, nephrotic syndrome 2. Spontaneous peritonitis in adults (10-30% of hospitalised cirrhotics) alcoholic cirrhosis, postnecrotic cirrhosis, viral hepatitis, heart failure, metastasis, autoimmune… 3. Tuberculous peritonititis

Microbiology 70% enteric pathogens Escherichia coli Klebsiella pneumoniae Streptococcus pneumoniae Enterococci Staphylococcus aureus (rare) Anaerops For anaerobs, 75% bacteremia For anaerobs, 75% bacteremia

Pathogenesis Hematogenous Lymphatic transmural migration through GI tract Vaginal Through Fallopian tubes

S&S Acute fever Abd. pain Nausea, vomiting Tenderness, rebound Hypoactive bowel sounds

In patients with ascites, peritoneal irritation findings may not be seen Fever >37.8˚C

TB peritonitis Fever Weight loss Fatigue Night sweats Abdominal distension Multiple nodules on peritoneum and omentum (in laparoscopy)

Laboratuvar In ascitis fluid Cell count (>250 PMN/mm 3, > 500 leukocyte/mm 3 ) Protein (serum-ascites albumin gradient <1,1) LDH (ascites/serum >0,4) Gram Staining (60-80% negative) Culture (40% negative)

CT: to exclude any primary focus of intaabdominal inf. Response to emprical antibiotics within h.

Tx Emprical ampicillin+aminoglycoside 3rd gen. Ceph. piperacilin piperacilin-tazobactam, ampicillin- sulbactam carbapenems levofloxacine, moxifloxacin

Secondary peritonitis The integrity of GI tract is broken Etiology depend upon the damaged site Polymicrobial E.coli (early mortality) B. fragilis (late abscess development)

Secondary peritonitis 1. Gastrointestinal perforation (appendicitis, gastroduodenal ulcer perforation, cancer perforation, bile duct perforation…) 2. Intestinal ischemia-perforation (mesenteric occlusion, strangulation of hernia) 3. Postoperative peritonitis (anastomosis leak, blind loop leak, iatrogenic peroperative damages)

4. Posttraumatic peritonitis (penetrating, blunt trauma) 5. Pelvic peritonitis (septic abortus, puerperal sepsis, salpyngitis, purulant prostatitis)

Microbiology Aerops Aerops Escherichia coli %65 Proteus spp. %25 Klebsiella spp. %20 Pseudomonas spp. %15 Enterococcir %15 Streptococcir %10 Anaerops Anaerops Bacteroides fragilis %80 Bacteroides spp. %30 Clostridium spp. %65 Peptostreptococcus spp. %25 Peptococcus spp. %15 Fusobacterium spp. %20

Clinical Abd. pain (severe on the inflamed site, increases on movement), anorexia, nausea, vomiting, dehydration due to hypovolemia, chills, fever. Hypotention, tachycardia, oliguria, tachypnea (due to hypovolemia, hypoxia, and acidosis Adynamic ileus

Tenderness, guarding, rebound: helpful for localising the site and the diagnosis. Bowel sounds: initially hyperactive then silence….

Dx Leukocytosis, left-shift (stabs) Hemoconcentration and dehydration: high hematocrit and BUN High ALT/AST, low platelets, acidosis, high D-dimer Plain abdominal X-ray, chest X-ray Abdominal US, CT Surgical or CT-guided sample: gram and culture, BC (20-30% bacteremia)

Prognosis Age Co-morbidity Peritoneal contamination time “Foreign” substance (biliary and pancreatic secretions) Microorganism Mortality: %

Tx Surgery + supportive+ antibiotics (leukocytes, fever, bowel sounds…) 5- 7 days after an appropriate surgical control

Ampirik antibiyoterapi Community-acq. Community-acq. mild-moderate cefazolin+metronidazol severe piperacillin-tazobactam ceftriaxon+metronidazol clindamicin+gentamicin imipenem Hospital acq. Hospital acq. piperacillin+metronidazol +aminoglycoside imipenem+/-aminoglycoside Enterokococci, Candida ??

Treatment Guidelines for Intra-abdominal Infections CID 2003:37 (15 October)