Initial Management Initial Management For Suspected or Confirmed Intra-Abdominal Infections
Routine history, physical examination, and laboratory studies (A-II) Rapid restoration of intravascular volume (A-II)
Source control
In adult patients not undergoing immediate laparotomy, CT scan is the imaging modality of choice to determine the presence of an intra-abdominal infection and its source (A-II).
Microbiology
> Gram stains may help define the presence of yeast (C-III). > For higher risk patients, aerobic and anaerobic cultures should be routinely obtained, particularly in patients with prior antibiotic exposure who are more likely to harbor resistant pathogens (A-II).
> If a patient appears clinically toxic or is severely immunocompromised, blood cultures may be helpful in determining duration of antimicrobial therapy (B-III).
> Susceptibility testing for Pseudomonas, Proteus, Acinetobacter, Staphylococcus aureus, and predominant (up to two) Enterobacteriaceae should be performed, as these are more likely to yield resistant organisms (A-III).
> If there is significant resistance (greater than 10-20%) of a common community isolate (eg, E. coli) to an antimicrobial regimen in widespread local use, routine culture and susceptibility studies should be obtained for perforated appendicitis and other community-acquired intra-abdominal infections (B-III).
Table 1. Clinical Factors Predicting Failure of Source Control for Intra-Abdominal Infections
Delay in the initial intervention (> 24 h) High severity of illness (APACHE II ≥ 15)* Advanced age Comorbidity and degree of organ dysfunction Low albumin Poor nutritional status Degree of peritoneal involvement/diffuse peritonitis Inability to achieve adequate debridement or control of drainage Presence of malignancy
*Knaus WA, Zimmerman JE, et al. APACHE - acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med. 1981;9:591-597.
