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Table 4 Empiric antimicrobial therapy for hospital-acquired complicated intra-abdominal infections (Hospitals groups C and D)

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 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
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)
  1. KEY: AFG anidulafungin, AMK amikacin, CAS caspofungin, CAZ ceftazidime, CST colistin, CZA ceftazidime/avibactam, C/T ceftolozane/tazobactam, d days, DD double dose, ETP ertapenem, FEP cefepime, h hours, IPM imipenem, LZD linezolid, MEM meropenem, MFG micafungin, MIC minimal inhibitory concentration, MRSA Methicillin-resistant Staphylococcus aureus, MTZ metronidazole, TGC tigecycline, TZP piperacillin/tazobactam, XDRO Extensively-drug resistant organism
  2. N.B.*Screening for XDRO carriage is recommended in Hospitals B, C and D (grade 2B)
  3. 1Risk factors for MRSA acquisition include: history of previous colonization, history of close proximity to cases harboring/infected with MRSA, prior treatment failure due to an MRSA-related infection, and extensive exposure to antibiotics
  4. 2The 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
  5. 3Linezolid should be used in patients at risk of vancomycin-resistant Enterococci (VRE)-related infection only. Risk factors for VRE include: previous antibiotic therapy, prolonged hospitalization, hospitalization in an intensive care unit, severe illness or underlying pathology, invasive procedures, gastrointestinal surgery, organ transplantation, and close proximity to other VRE-positive patients
  6. 4The duration of antimicrobial therapy is extended depending on concomitant presence of bacteremia, rate of resolution of fever and leukocytosis, in addition to severity and correction of organ failure
  7. 5In case of post-operative cholangitis or cholangitis complicated by septic shock, add an echinocandin (AFG, CAS or MFG) to the antibiotic regimen (grade 2A)
  8. 6If residual stones or obstruction of the bile tract are present, treatment should be continued until these anatomical problems are resolved