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Table 2 Empiric antimicrobial therapy for community-acquired complicated intra-abdominal infections

From: The 2018 Lebanese Society of Infectious Diseases and Clinical Microbiology Guidelines for the use of antimicrobial therapy in complicated intra-abdominal infections in the era of antimicrobial resistance

Type of infection Classification Sub-classification Duration of antimicrobial therapy Recommendation
Peritoneal/ Intra-peritoneal Mild to moderate with hemodynamic stability (no spillage of intraluminal material in the peritoneum) Acute stomach or duodenal/ proximal jejunal perforation in the absence of gastric acid-reducing therapy or malignancy, and when the patient is operated within 24 h 24 h (grade 3A) No risk of 3GCRE
-[AMC + AMG (grade 2B)]
Or
-[3GC (CRO or CTX or ZOX) + MTZ ± AMG (grade 2B)]
-No additional antibiotic coverage against Enterococci (grade 1)
-No additional antifungal coverage (grade 2B)
Risk of 3GCRE
-ETP (grade 1) or TGC (grade 2B)
-No additional antibiotic coverage against Enterococci (grade 1)
-No additional antifungal coverage (grade 2B)
Bowel injuries attributed to penetrating, blunt, or iatrogenic trauma repaired within 12 h without any intraoperative contamination of the operative field by enteric contents 24 h (grade 1)
Acute appendicitis without evidence of perforation, abscess, local peritonitis, or spillage of intraluminal material in the peritoneum 24 h (grade 1)
Mild to moderate with hemodynamic stability (with intra-abdominal contamination with intraluminal material) Acute stomach or duodenal/ proximal jejunal perforation in case of delayed operation > 24 h, the presence of gastric malignancy or the presence of therapy reducing gastric acidity and the infection is ongoing or persistent 4–7 d1 (grade 3B) No risk of 3GCRE
-[AMC + AMG (grade 2B)]
Or
-[3GC (CRO or CTX or ZOX) + MTZ ± AMG (grade 2B)]
-No additional antibiotic coverage against Enterococci (grade 1)
-No additional antifungal coverage (grade 2B)
Risk of 3GCRE
-ETP (grade 1) or TGC (grade 2B)
-No additional antibiotic coverage against Enterococci (grade 1)
-No additional antifungal coverage (grade 2B)
Bowel injuries attributed to penetrating, blunt, or iatrogenic trauma repaired within 12 h (with intra-abdominal contamination with intraluminal material) 4–7 d1 (grade 3B)
Acute appendicitis (with intra-abdominal contamination with intraluminal material) 4–7 d1 (grade 3B)
Severe (Appendicitis, colonic non-diverticular perforation, diverticulitis, gastro-duodenal perforations, small bowel perforation, pelvic inflammatory disease, post-traumatic perforation) No secondary bacteremia; Adequate source control 4 d1 (grade 2A) - CAR (IPM or MEM) (grade 1)
- Use glycopeptides for Enterococci treatment in immunocompromised patients or those with recurrent infection (grade 2B)
- Antifungal therapy:
• FLC as targeted therapy in high risk2, non-septic, immunocompetent patients (grade 2B)
• Echinocandins (AFG, CAS or MFG) in septic or immunocompromised patients (grade 3B)
Secondary bacteremia; Adequate source control with successful treatment of bacteremia 7 d1 (grade 2B)
No adequate source control >  7–14 d1 (grade 3B)
Cholecystitis Grade 1 24 h (grade 1) AMC (grade 2B) or CXM (grade 2B) or 3GC (CRO or CTX or ZOX) (grade 2A)
Grade 2 4–7 d (grade 3B) (adequate source control) No risk of 3GCRE
3GC (CRO or CTX or ZOX) + MTZ (grade 2A)
Risk of 3GCRE
ETP (1) or TGC (2B) or TZP (3B)
Grade 3 ≥ 5 d 3 (grade 3B) CAR (IPM or MEM) (1)
Cholangitis Mild to moderate 4–7 d 4 (grade 3B) (adequate source control) No risk of 3GCRE
3GC (CRO or CTX or ZOX) + MTZ (grade 2A)
Risk of 3GCRE
ETP (grade 1) or TGC (grade 2B) or TZP (grade 3B)
Severe (including perforation, emphysema, and necrosis of gall bladder, etc.) ≥ 5 d 3,4 (grade 3B) CAR (IPM or MEM) + glycopeptide (grade 1)
  1. KEY: AFG anidulafungin, AMC amoxicillin/clavulanic acid, AMG aminoglycoside, CAS caspofungin, CRO ceftriaxone, CTX cefotaxime, CXM cefuroxime, d days, ETP ertapenem, FLC fluconazole, h hours, IPM imipenem, MEM meropenem, MFG micafungin, MTZ metronidazole, TGC tigecycline, TZP piperacillin/tazobactam, XDRO extensively-drug resistant organism, ZOX ceftizoxime, 3GC third generation cephalosporin, 3GCRE third generation cephalosporin-resistant Enterobacteriaceae
  2. N.B
  3. 1The decision to continue, revise, or stop antimicrobial therapy should be made on the basis of clinician judgment and laboratory information (grade 3A). Criteria to evaluate clinical efficacy and duration of antimicrobial therapy are presence of comorbidities, quality of the surgical procedure, time to apyrexia, normalization of leukocyte count, normalization of bowel movements. Severity and correction of organ failure are criteria for evaluating treatment efficacy severe infections only
  4. 2High-risk patients include those with advanced age, high disease severity and high risk of death
  5. 3Duration extended depending on: severity of organ failure, concomitant presence of bacteremia, rate of resolution of fever and leukocytosis, and correction of organ failure
  6. 4If residual stones or obstruction of the bile tract are present, treatment should be continued until these anatomical problems are resolved (grade 3B)