Surgical intra-abdominal infections

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Including: biliary tract infections, appendicitis, diverticulitis, peritonitis, suspected perforation.

Recommended total duration:

  • 5 days after adequate source control (either surgery or radiological drainage).
  • 7 days for uncomplicated infections not requiring surgical intervention.
  • After uncomplicated appendicectomy/cholecystectomy postoperative antibiotics may not be required.
  • The role of antibiotics in uncomplicated acute diverticulitis is unclear.

 

Required investigations

Blood cultures before starting antibiotics.

Antibiotic recommendation

Recommended total duration:

  • 5 days after adequate source control (either surgery or radiological drainage).
  • 7 days for uncomplicated infections not requiring surgical intervention.
  • After uncomplicated appendicectomy/cholecystectomy postoperative antibiotics may not be required.
  • The role of antibiotics in uncomplicated acute diverticulitis is unclear.
Recommended antibiotics

Amoxicillin 1g every 8 hours IV

AND

Gentamicin (use NHS Lothian Calculator located AMT intranet page)

AND

Metronidazole 400mg every 8 hours orally (500mg every 8 hours IV if oral route unavailable)

Penicillin allergy or known MRSA carriage

Vancomycin (use NHS Lothian Calculator located AMT intranet page) - target trough level 10-15mg/L

AND

Gentamicin  (use NHS Lothian Calculator located AMT intranet page)

AND

Metronidazole 400mg every 8 hours orally (500mg every 8 hours IV if oral route unavailable)

72 hour review

@48-72 HRS REVIEW WITH SENIOR TEAM MEMBER

OTHERWISE

  • Has an AKI developed whilst in hospital? AKI 1 is defined as x1.5 rise in creatinine from baseline.
  • Has the patient developed new hearing or balance symptoms (think about gentamicin toxicity)?
  • Has the patient grown gentamicin-resistant organisms?

If the answer is “No” to all these questions and IV antibiotics are still required, continue the above IV regimens to Day 5.

IV Antibiotic Recommendations (after 5 days) if IV to oral switch not possible:

  • Phone microbiology to discuss patient.
  • Gentamicin is associated with hearing and balance problems; only continue regimens containing gentamicin past 5 days on recommendation from Microbiology/Infectious Disease.

IV to oral switch

Recommended total duration:

  • 5 days after adequate source control (either surgery or radiological drainage).
  • 7 days for uncomplicated infections not requiring surgical intervention.
  • After uncomplicated appendicectomy/cholecystectomy postoperative antibiotics may not be required.
  • The role of antibiotics in uncomplicated acute diverticulitis is unclear.
Preferred

Co-trimoxazole 960mg every 12 hours orally

PLUS

Metronidazole 400mg every 8 hours orally

Alternative

Co-amoxiclav 625mg every 8 hours orally

Suitable for those ≤ 65 years old with a low risk of C.diff infection.

See Prevention, diagnosis and management of CDI.

Notes

Likely organisms: Coliforms, anaerobes (for example Bacteroides), Enterococci, Anginosus group streptococci.

  • Metronidazole has excellent oral bioavailability – only give IV in severe illness, suspected malabsorption or oral route compromised.
  • Dual-anaerobe cover: adding Metronidazole to Co-amoxiclav: is not usually required.  
  • General advice on management of sepsis can be found here Sepsis 6
  • Sending samples from abscess drainage or at the time of surgery is helpful.