Type of infection | Classification | Sub-classification | Hospitals Group C (>  20% 3G resistance in nosocomial Enterobacteriaceae and >  20% resistance to CAZ and CAR in nosocomial P. aeruginosa) | Hospitals Group D (> 20% resistance to 3GC and CAR in nosocomial Enterobacteriaceae | ||
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Duration of antimicrobial therapy | Recommendation | 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 | 7 d (grade 2B) | If the patient was not on a CAR-containing regimen: [CAR (IPM or MEM) (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) If the patient was on a CAR containing regimen: [(TZP or CAZ or FEP) + TGC] (grade 3C) + Echinocandin (AFG, CAS or MFG) (grade 2A) Or [C/T (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) *In case of positive XDRO screen, modify antibacterial regimen as per culture results. | 7 d (grade 2B) | If the patient was not on a CAR-containing regimen: [CAR (IPM or MEM) (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) If the patient was on a CAR containing regimen: [(TZP or CAZ or FEP) + TGC] (grade 3C) + Echinocandin (AFG, CAS or MFG) (grade 2A) Or [C/T (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) *In case of positive XDRO screen, modify antibacterial regimen as per culture results.. |
Bowel injuries attributed to penetrating, blunt, or iatrogenic trauma repaired within 12 h without any intraoperative contamination of the operative field by enteric contents | 7 d (grade 2B) | 7 d (grade 2B) | ||||
Acute appendicitis without evidence of perforation, abscess, local peritonitis, or spillage of intraluminal material in the peritoneum | 7 d (grade 2B) | 7 d (grade 2B) | ||||
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 | 7–14 d2 (grade 2B) | If the patient was not on a CAR-containing regimen: [CAR (IPM or MEM) (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) If the patient was on a CAR containing regimen: [(TZP or CAZ or FEP) + TGC] (grade 3C) + Echinocandin (AFG, CAS or MFG) (grade 2A) Or [C/T (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) *In case of positive XDRO screen, modify antibacterial regimen as per culture results. | 7–14 d2 (grade 2B) | If the patient was not on a CAR-containing regimen: [CAR (IPM or MEM) (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) If the patient was on a CAR containing regimen: [(TZP or CAZ or FEP) + TGC] (grade 3C) + Echinocandin (AFG, CAS or MFG) (grade 2A) Or [C/T (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) *In case of positive XDRO screen, modify antibacterial regimen as per culture results. | |
Bowel injuries attributed to penetrating, blunt, or iatrogenic trauma repaired within 12 h (with intra-abdominal contamination with intraluminal material) | 7–14 d2 (grade 2B) | 7–14 d2 (grade 2B) | ||||
Acute appendicitis (with intra-abdominal contamination with intraluminal material) | 7–14 d2 (grade 2B) | 7–14 d2 (grade 2B) | ||||
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 | 7–14 d2 (grade 2B) | CAR sparing regimen: [C/T + MTZ + AMK ± CST (grade 2B) + Glycopeptide or LZD3 (grade 3C)] + Echinocandin (AFG, CAS or MFG) (grade 2A) If C/T is not available: 1- CAR sparing regimen: [(TZP or CAZ or FEP) + CST + TGC + Glycopeptide or LZD3 (grade 3C)] + Echinocandin (AFG, CAS or MFG) (grade 2A) Or 2- [CAR (IPM or MEM) + CST + Glycopeptide or LZD3 (grade 3C)] + Echinocandin (AFG, CAS or MFG) (grade 2A) *In case of negative XDRO screen or intra-operative cultures for Pseudomonas spp., discontinue colistin. | 7–14 d2 (grade 2B) | If MEM MIC ≤ 16 μg/mL: 1-[MEM (DD and prolonged infusion over 4 h) + TGC ± AMK (grade 3C) + Glycopeptide or LZD3 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) Or 2- CAR sparing regimen: [CZA + TGC ± AMK (grade 2B) + Glycopeptide or LZD3 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) If MEM MIC > 16 μg/mL: 1-[CZA + TGC ± AMK (grade 2B) + Glycopeptide or LZD3 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) Or 2- [dual CAR regimen (MEM + ETP) + CST + TGC ± AMK (grade 3C) + Glycopeptide or LZD3 (grade 2A)] + Echinocandin (AFG, CAS or MFG) (grade 2A) *In case of negative XDRO screen or intra-operative cultures for CRE, discontinue colistin. | |
Secondary bacteremia; Adequate source control with successful treatment of bacteremia | 10–14 d2 (grade 2B) | 10–14 d2 (grade 2B) | ||||
No adequate source control | ≥ 14 d2 (grade 2B) | ≥ 14 d2 (grade 2B) | ||||
Cholecystitis | Grade 1 | – | 5 d (grade 2B) | 1- CAR sparing regimen: [(TZP or CAZ or FEP) + TGC] (grade 3B) Or 2- [CAR (IPM or MEM) (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] | 5 d (grade 2B) | If the patient was not on a CAR-containing regimen: [CAR (IPM or MEM) (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] If the patient was on a CAR containing regimen: [(TZP or CAZ or FEP) + TGC] (grade 3C) *In case of positive XDRO screen, modify antibacterial regimen as per culture results. |
Grade 2 | – | 7–10 d (grade 2B) (adequate source control) | 7–10 d (grade 2B) (adequate source control) | |||
Grade 3 | – | ≥ 10–14 d4 (grade 2B) | ≥ 10–14 d4 (grade 2B) | |||
Cholangitis5,6 | Mild to moderate | – | 7–10 d (grade 2B) | 1- CAR sparing regimen: [(TZP or CAZ or FEP) + TGC] (grade 3B) Or 2- [CAR (IPM or MEM) (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] | 7–10 d (grade 2B) | If the patient was not on a CAR-containing regimen: [CAR (IPM or MEM) (grade 3C) + anti-MRSA antibiotics1 (grade 2A)] If the patient was on a CAR containing regimen: [(TZP or CAZ or FEP) + TGC] (grade 3C) *In case of positive XDRO screen, modify antibacterial regimen as per culture results. |
Severe (including perforation, emphysema, and necrosis of gall bladder, etc.) | – | ≥ 10–14 d4 (grade 2B) | ≥ 10–14 d4 (grade 2B) |