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