1. ABDOMINAL INFECTIONS AND PUERPURAL SEPSIS
Samuel Mwaniki

2. OBJECTIVES
Describe pathogenesis & clinical characteristics of intra-abdominal infections
Identify most likely etiologic organism(s)
Review appropriate drug therapy

3. INTRA-ABDOMINAL INFECTIONS
Infections contained within the peritoneum or
retroperitoneal space.
Peritoneal cavity contains:
Stomach
Jejunum, Ileum
Appendix
Large intestine (colon)
Liver, gallbladder and spleen
Retroperitoneal space:
Duodenum
Pancreas
Kidneys

4. Intra-abdominal Infections
Appendicitis
Peritonitis
Intra-abdominal Abscess
Diverticulitis
Antibiotic-Associated Diarrhea - Clostridium difficile
Food Poisoning/Traveler’s Diarrhea – E. Coli
PUD - Helicobacter pylori
Pelvic Inflammatory Disease

5. GI Microflora Stomach: H. Pylori, Lactobacilli Upper Intestine:
Streptococci, Enterococci, Staphylococci, E. Coli, Klebsiella, Bacteroides
Ileum:
Streptococci, Staphylococci, Escherichia coli, Klebsiella, Enterobacter, Bacteroides, Clostridium
Colon:
Bacteroides, Peptostreptococci, Clostridium, Bifidobacterium, Escherichia coli, Klebsiella, Enterobacter, Enterococci, Staphylococci

6. Peritonitis
Inflammation of the serous lining of the peritoneal cavity due to:
Microorganisms
Chemicals
Irradiation
Foreign body injury

7. Primary (Spontaneous Bacterial Peritonitis)
No focus of disease is evident
Arises without a breach in the peritoneal cavity or GIT
Bacteria transported from blood stream to peritoneal cavity (Cirrhosis, CAPD)
Usually monomicrobial

8. Secondary
Acute perforation of the GI tract (diverticulitis - ), appendix (appendicitis), gallbladder, tumor perforations)
Community acquired or nosocomial
Usually polymicrobial
Post-operative peritonitis
Post-traumatic peritonitis

9. Tertiary
Peritonitis in a critically ill patient which persists or recurs at least 48 h after apparently adequate management of primary or secondary peritonitis

10. Clinical Symptoms
Abdominal pain
Anorexia (N/V)
Fever (38-40 ºC)
Abdominal distention and tenderness
Hypoactive or faint bowl sounds
Leukocytosis

11. Normally:
20 to 50 mL transudate
Peritoneal membrane measures approx. 1.7 metres square
WBC < 300 cells/mm3
Protein: <3 g/dL
Bacterial peritonitis:
300 to 500mL inflow/hr resulting in hypovolemia.
WBC > 300 cells/mm3
Gram stain + for bacteria

12. Microbiology
Blood cultures often –ve
Peritoneal fluid used (parecentesis)
Health care associated intra-abdominal infection usually due to nosocomial organisms particular to the site of the operation and specific hospital and unit

13. Community acquired infections
infections derived from stomach, duodenum, biliary system and proximal small bowel:
Gram positive and Gram negative aerobic and facultative bacteria
distal small bowel:
Gram negative facultative and aerobic bacteria
Anaerobes
large bowel:
Facultative and obligate anaerobic bacteria
Streptococi and enterococci commonly present

14. Aerobes:
GN Bacilli: E. Coli, Klebsiella,Enterobacter, Proteus mirabilis, Pseudomonas aeruginosa
GP Cocci: Enterococcus spp e.g. E. faecalis, Streptococcus, S.aureus, Coagulase –ve Staphylococcus

15. Anaerobes:
GN Bacilli : B.fragilis, Prevotella, Pophyromonas
GP Cocci: Clostridium spp, Peptostreptococcus.
Fungi:
C. albicans

16. Appendicitis Highest incidence 10-19y/o Male > female
Pathophysiology: Relationship to onset of sx
0-24h after sx onset: obstruction within appendix , inflammation & occlusion of vascular & lymphatic flow, bacterial overgrowth then necrosis.
>48h after sx onset: perforation, abscess/peritonitis
Early sx: dull, non-localized pain, indigestion,bowel irregularity, flatulence
Later sx: pain/tenderness more localized, N/V, Fever > 39 degrees celcius, leukocytes >15000: perforation likely

17. Management
Acute, non-perforated appendicitis
cefazolin + metronidazole
Perforated appendicitis
Cover enteric gram – rods and anaerobes
(2nd/3rd generation ceph or FQ) + metronidazole, Cefoxitin, piperacillin/tazobactam, ampicillin/sulbactam, imipenem
Antibiotics are started before surgery, continued for days
Switch to PO based on patient status

18. Intra – abdominal Abscess
Abscess: purulent collection of fluid, necrotic debris, bacteria, inflammatory cells that is walled off/encapsulated by adjacent healthy cells in an attempt to keep pus from infecting neighboring structures.
Encapsulation can prevent immune cells/abx from attacking contained bacteria, low O2 in capsule, anaerobes thrive
here!
A Result of chronic inflammation, develop over days-yrs
Located within peritoneal cavity or visceral organs
May range from a few milliliters to a liter in volume

19. Ruptured abscess
Spread of bacteria + toxins into peritoneum - peritonitis
Spread of bacteria + toxins into systemic circulation – sepsis, multi-organ failure, death
Presentation:
Nonspecific low grade or spiking fever, abdominal pain/discomfort +/- distension
Labs:
Leukocytosis, +/- positive blood cultures, +/-hyperglycemia
Ultrasound, GI contrast study, or CT scan may be used for evaluation

20. Microbiology
Usually mixed infection: aerobes & anaerobes within the same abscess
E. coli
Klebsiella
Enterococci
B. fragilis
Clostridium

21. Management
Combination of modalities:
Surgical: Prompt drainage of abscess (secondary peritonitis) and/or debridement, Resection of perforated colon, small intestine, ulcers, Repair of trauma.
Support of Vital functions: Blood pressure/fluid replacement, Monitor heart rate, Monitor urine out put (0.5 ml/kg/hr)
Appropriate antimicrobial therapy

22. Empiric Antibiotic Therapy
MUST include aerobic/anaerobic coverage
Agents with Aerobic and Anaerobic activity:
Ampicillin/sulbactam - (enterococci)
Piperacillin/tazobactam - (enterococci)
Imipenem/cilistatin
Meropenem
Ertapenem
Aminoglycoside + clindamycin or metronidazole
Tigecycline
Moxifloxacin - (active against 83% of Bacteroides strains) + metronidazole

23. Antibiotic Associated Diarrhoea
Antibiotic therapy (broad spectrum agents: clindamycin, ampicillin, 3rd generation cephalosporins are most common)
Disruption of normal colonic flora
C. difficile colonization (gram +, spore forming anaerobe)
Release of toxins A (enterotoxin), B (cytotoxin), & binary toxin
CDT (associated w/ recent outbreaks)
Damage to colonic mucosa (pseudomembranous plaques),inflammation, intestinal fluid secretion
Antibiotic Associated Diarrhoea

24. Treatment
FIRST LINE:
Metronidazole (Treatment of Choice)
250mg PO QID or 500mg PO/IV TID x days
ALTERNATIVE: (if pregnant, not responding to metronidazole or
recurrences)
Vancomycin
125mg PO QID x days +/- rifampin 600mg PO BID
Always stop the drug responsible for causing the infection as soon as possible!

25. PUERPURAL SEPSIS Definition of Puerpurum
The time from the delivery of the placenta through the first few weeks after the delivery.
6 weeks in duration.
By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the non pregnant state.

26. Puerperal Infection
Any bacterial infection of the genital tract after delivery. Incidence: 6%. The most important cause of maternal death.
Puerperal Morbidity
Temperature 38.0℃ or higher, the temperature to occur on any 2 of the first 10days postpartum, exclusive of the first 24 hours, and to be taken by mouth by a standard technique at least four times daily.

27. Risk factors
Anaemia
Hemorrhage
Episiotomy and CS
Placenta retention
Hospital contamination

28. Common pathogens
Aerobes
Group A, B, and D streptococci
Gram-negative bacteria: Escherichia coli, Klebsiella
Staphylococcus aureus

29. Anaerobes
Peptostreptococcus species
Bacteroides fragilis group
Clostridium species
Other
Chlamydia trachomatis
Mycoplasma species

30. Manifestation
Acute vulvitis, vaginitis, cervicitis and endometritis
Uterine infection
Adnexal infections
Septic pelvic thrombophlebitis
Sapremia (blood poisoning resulting from absorption of putrefaction matter from the uterus)

31. MERCI BEACOUP, MADAME MADEMOISELLE ET MESSRS!