Antibiotics Protocol - November 2023.pdf

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Protocol of antibiotics use and treatment
of infectious diseases in the hospital
November 2023
Prepared by Clinical pharmacy department:
Dr. Nadeen Drahem
Dr. Omnya Wagdy
Dr. Amira Elkhodary
‫الصيدلة‬ ‫قسم‬ ‫رئيس‬
‫االكلينيكية‬
‫الصيدلية‬ ‫عام‬ ‫مدير‬
‫المركز‬ ‫عام‬ ‫مدير‬
‫دراهم‬ ‫نادين‬ .‫د‬
‫فتحي‬ ‫أسماء‬ .‫د‬
‫سالمة‬ ‫كمال‬ .‫د‬

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Objective
Antibiotics are important in the management of infections. They should be used properly as guided by the 5Rs of antimicrobials
use, namely, right choice of antibiotic for a particular disease, administered at the right dose, for the right duration, at the right
frequency via the right route of administration.
Therefore, this antibiotics use protocol aims for:
• Elimination of the use of unnecessary or ineffective antibiotics and restriction of the use of unnecessarily powerful ones.
• Proper empirical treatment of infectious diseases according to international guidelines and evidence-based medicine.
In order to:
• Combat emergence of antibiotic resistance and preserve the effectiveness of current antibiotics and extend their lifespan.
• Achieve better prognosis and reduce mortality,
• Reduce unnecessary cost of antibiotics.
Scope
This antibiotics use protocol is addressed to the health care team in the hospital including:
• Physicians: Safe and appropriate prescribing according to antimicrobial and infectious diseases guidelines and ensuring
antimicrobials are ordered so that they are administered within appropriate time frames.
• Pharmacists: Timely and accountable supply of antimicrobials, appropriate and timely advice to prescribers and nurses with
regard to the selection, dose, route and duration
• Nurses: Ensuring safe and timely administration, preparation of prescribed antimicrobials and performing sensitivity tests.
• Pharmacy stock: Provide the hospital with the required antibiotics for infectious disease treatment.

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Table of Contents
Spectrum of available antibiotics currently in the hospital .............................................................................................................5
Pneumonia....................................................................................................................................................................................6
Community acquired pneumonia (CAP)......................................................................................................................................6
Hospital acquired Pneumonia (HAP).........................................................................................................................................10
Ventilator- Associated Pneumonia (VAP)..................................................................................................................................12
Aspiration Pneumonia..............................................................................................................................................................14
Urinary Tract Infections ...............................................................................................................................................................15
Asymptomatic bacteriuria (ABU)..............................................................................................................................................15
Uncomplicated Cystitis.............................................................................................................................................................16
Recurrent urinary tract infection (rUTI) ....................................................................................................................................17
Uncomplicated pyelonephritis..................................................................................................................................................18
Complicated urinary tract infection ..........................................................................................................................................20
Catheter-associated UTIs (CA-UTI)............................................................................................................................................21
Urosepsis.................................................................................................................................................................................22
Sepsis..........................................................................................................................................................................................23
Extended or Continuous infusion method.................................................................................................................................28
Intra-abdominal infections ..........................................................................................................................................................29
Acute cholecystitis ...................................................................................................................................................................31
Acute Cholangitis .....................................................................................................................................................................33
Acute appendicitis ...................................................................................................................................................................35

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Acute pancreatitis....................................................................................................................................................................37
Intra-abdominal abscess ..........................................................................................................................................................39
Acute colonic diverticulitis .......................................................................................................................................................41
Spontaneous bacterial peritonitis/ (SBP) ..................................................................................................................................43
Spontaneous bacterial empyema (SBE).....................................................................................................................................43
Pyogenic hepatic abscess .........................................................................................................................................................45
Clostridium Difficile.....................................................................................................................................................................48
Management in adults..........................................................................................................................................................49
Management in pediatrics ....................................................................................................................................................50
Infective endocarditis (IE) ............................................................................................................................................................51
Skin and Soft tissues infections....................................................................................................................................................65
Cellulitis...................................................................................................................................................................................65
Erysipelas.................................................................................................................................................................................68
Necrotizing infections (NSTI) ....................................................................................................................................................69
Diabetic foot infection .............................................................................................................................................................70
Surgical site infection ..................................................................................................................................................................73
Mesh infections .......................................................................................................................................................................75
Secondary post operative peritonitis........................................................................................................................................78
Postoperative mediastinitis after cardiac surgery .....................................................................................................................79
Perianal abscess ..........................................................................................................................................................................82
Conversion to Oral Route.................................................................................................................................................................83
Dose Modification for Renal and Hepatic Impairment ..............................................................................................................................84

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Spectrum of available antibiotics currently in the hospital
# # Recommended Active Variable Not Recommended
Gram-Positive Gram-Negative Anaerobes
Atypicals
VRE
E.
faecalis
MRSA
MSSA
Coag.-Negative
Staph.
B-Hemolytic
Strept.
S.
pneumoniae
Viridans.
strept.
H.
influanzae
E.
coli
Klebsiella
spp.
Proteus
spp.
Serratus
spp.
Enterobacter
spp.
Pseudomonas
spp.
Oral
anaerobes
Abdominal
anaerobes
Ampicillin-Sulbactam
Amoxacillin-Clavulanate
Pipracillin-Tazobactam
Ceftriaxone
Cefotaxime
Cefepime
Meropenem
Ciprofloxacin
Levofloxacin
Vancomycin
Linezolid
Amikacin
Gentamicin
Metronidazole

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Pneumonia
Community acquired pneumonia (CAP)
Definition An acute infection of the pulmonary parenchyma acquired outside of the hospital which include the new onset of fever, purulent
sputum, leukocytosis, and decline in oxygenation
Causative organisms Gm +ve bacteria: Streptococcus pneumoniae and Staphylococcus aureus.
Gm-ve bacteria: Haemophilus influenzae, Enterobacteriaceae such as Klebsiella pneumonia or Escherichia coli, and Moraxella
catarrhalis.
Atypical bacteria: Mycoplasma pneumoniae, Legionella species, Chlamydia pneumoniae
MRSA and Pseudomonas aeruginosa in susceptible population.
But the epidemiology of CAP is constantly changing and requires ongoing evaluation.
Classification 1. Non severe inpatient CAP
2. Severe inpatient CAP
Criteria for defining severe CAP: either one major criterion or three or more minor criteria
Major Criteria • Septic shock with need for vasopressors
• Respiratory failure requiring mechanical ventilation
Minor Criteria • Respiratory rate > 30 breaths/min
• PaO2/FIO2 ratio < 250
• Multilobar infiltrates
• Confusion/disorientation
• Uremia (blood urea nitrogen level > 20 mg/dl)
• Leukopenia due to infection alone not chemotherapy induced (WBC count: 4,000 cells/ml)
• Thrombocytopenia (platelet count: 100,000/ml)
• Hypothermia (core temperature: 368C)
• Hypotension requiring aggressive fluid resuscitation
When to obtain
Cultures?
• Cultures from respiratory secretions and blood should be obtained before antimicrobial therapy in adults with CAP managed in
the hospital setting who:

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1. are classified as severe CAP, especially if they are intubated.
2. are being empirically treated for MRSA or P. aeruginosa.
3. were previously infected with MRSA or P. aeruginosa, especially those with prior respiratory tract infection.
4. have risk factors for MRSA/Pseudomonas: were hospitalized and received parenteral antibiotics, whether during the
hospitalization event or not, in the last 90 days either if initial empiric therapy for these agents are initiated or not.
To either identify resistant pathogens to confirm need for targeted therapy or to allow de-escalation of therapy at 48 hours.
• When influenza viruses are circulating in the community, it is recommended to test for influenza with a rapid influenza
molecular assay (i.e., influenza nucleic acid amplification test), which is preferred over a rapid influenza diagnostic test (i.e.,
antigen test). During periods of low influenza activity, testing can be considered but may not be routinely performed.
Timing of antibiotics Non severe: within four hours of presentation. Delays in appropriate antibiotic treatment that exceed four hours have been associated
with increased mortality.
Severe: within one hour of presentation
Duration of therapy • Total duration of 5 days should be appropriate for most patients. Intravenous antibiotic regimens can be transitioned to oral
regimens with a similar spectrum activity as the patient improves within the 5 days period.
• Discontinuation of therapy should be guided by a validated measure of clinical stability (resolution of vital sign abnormalities
[heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature], ability to eat, and normal mentation), and
antibiotic therapy should be continued until the patient achieves stability for 48 hour and for no less than a total of 5 days
• Failure to achieve clinical stability within 5 days is associated with higher mortality and worse clinical outcomes. Such failure
should prompt assessment for a pathogen resistant to the current therapy and/or complications of pneumonia (e.g.,
empyema or lung abscess) or for an alternative source of infection and/or inflammatory response.
• Duration of therapy for CAP due to suspected or proven MRSA or P. aeruginosa should be 7 days.

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Empiric treatment strategies for inpatients with Community-acquired pneumonia
Standard
Regimen
Beta lactam
allergy
Recent hospitalization or
Parenteral antibiotics in
previous 90 days or locally
validated risk factors for
Pseudomonas
Prior Respiratory
Isolation of
Pseudomonas
Recent hospitalization or
Parenteral antibiotics in
previous 90 days or locally
validated Risk factors for
MRSA
Prior Respiratory
Isolation of MRSA
Nonsevere
inpatient
pneumonia
Beta Lactam +
Macrolide
OR Respiratory
Fluroquinolone
Respiratory
Fluroquinolone
Do not add Pseudomonas
coverage unless culture
results are positive.
Antipseudomonal
Beta lactam +
Antipseudomonal
Fluoroquinolone
and obtain cultures
Do not add MRSA coverage
unless culture results are
positive.
Add MRSA
coverage and
obtain cultures
Severe
inpatient
pneumonia
Beta Lactam +
Macrolide
OR B-lactam +
Respiratory
Fluroquinolone
Aztreonam +
Respiratory
Fluroquinolone
Antipseudomonal Beta
lactam + Antipseudomonal
Fluoroquinolone
and obtain cultures
Antipseudomonal
Beta lactam +
Antipseudomonal
Fluoroquinolone
and obtain cultures
Add MRSA coverage to
standard regimen or to
antipseudomonal regimen
and obtain cultures
Add MRSA
coverage and
obtain cultures
Agent Selection and dosing
Beta lactam Ampicillin+ sulbactam 1.5–3 g every 6 hours Antipseudomonal
Beta lactam
Piperacillin-tazobactam 4.5 g every 6 h
Cefotaxime 1–2 g every 8 hours Cefepime 2 g every 8 h
Ceftriaxone 1–2 g once daily Ceftazidime 2 g every 8 h
Macrolides Azithromycin 500 mg once daily Imipenem 500 mg every 6 h
Clarithromycin 500 mg twice daily Meropenem 1 g every 8 h
Respiratory
Fluroquinolone
Levofloxacin 750 mg daily Antipseudomonal
Fluoroquinolone
Levofloxacin 750 mg once daily
Moxifloxacin 400 mg daily Ciprofloxacin (IV) 400 mg every 8 h
Beta lactam
allergy
Aztreonam 2 g every 8 h MRSA coverage Vancomycin 15 mg/kg every 12 h (actual
body weight)
Linezolid 600 mg every 12 h

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Viral Pneumonia
It is recommended that anti-influenza treatment, such as oseltamivir, be prescribed for adults with CAP who test positive for influenza in the
inpatient setting, independent of duration of illness before diagnosis
It is recommended that standard antibacterial treatment be initially prescribed for adults with clinical and radiographic evidence of CAP who test
positive for influenza as bacterial pneumonia can occur concurrently with influenza virus infection or present later as a worsening of symptoms
in patients who were recovering from their primary influenza virus infection. appropriate agents for initial therapy include the same agents
generally recommended for CAP
Oseltamivir: 75 mg twice daily for 5 days
References IDSA and American thoracic society 2019 guidelines on treatment of CAP
Lexicomp
UpToDate

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Hospital acquired Pneumonia (HAP)
Definition An acute infection of the pulmonary parenchyma not incubating at the time of hospital admission and occurring 48 hours or more
after admission which include the new onset of fever, purulent sputum, leukocytosis, and decline in oxygenation.
Causative organisms S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli.
Therapy notes Extended infusion method of B lactams (Piperacillin-tazobactam, Cefepime, Imipenem, Meropenem) is recommended.
Duration of therapy 7 days.
• Recommended initial empiric antibiotic therapy
Standard Regimen Obtain sputum and blood culture
Start single Antipseudomonal antibiotic
Piperacillin-tazobactam (4.5 g every 6 h)
OR Cefepime (2 g every 8 h)
OR Imipenem (500 mg every 6 h)
OR Meropenem (1 g every 8 h)
OR Levofloxacin (750 mg IV once daily)
Pseudomonas Coverage
In case of any of the following
• Presence of factors increasing the likelihood of gram-negative
infection:
Prior intravenous antibiotic use within 90 days
Structural lung disease (ie, bronchiectasis or cystic fibrosis)
• High risk for mortality:
Need for ventilatory support due to pneumonia
Septic shock
Obtain sputum and blood culture
Combine two antipseudomonal antibiotics from different classes
Beta lactam Antipseudomonal:
OR Aztreonam (2g IV every 8 h) (In case of B lactam allergy)
PLUS
Non-Beta lactam Antipseudomonal
Levofloxacin (750 mg IV once daily)
OR Ciprofloxacin (400 mg IV every 8 h)
OR Gentamicin (5–7 mg/kg IV once) (avoided if alternatives available)

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MRSA coverage
• Presence of factors increasing the likelihood of MRSA infection:
Patients being treated in units where >20% of S. aureus isolates
are methicillin resistant
Patients in units where the prevalence of MRSA is not known
• High risk for mortality:
Need for ventilatory support due to pneumonia
Septic shock
Add to either of the preceding regimens:
Vancomycin (15 mg/kg IV every 8–12h, based on actual body weight) Consider a
loading dose of 25–30 mg/kg for severe illness to rapidly achieve target
concentrations, the initiation of the maintenance dose should occur at the next
dosing interval.
OR Linezolid (600 mg IV every 12h)
The choice between vancomycin and linezolid may be guided by patient-specific
factors such as blood cell counts, concurrent prescriptions for serotonin-
reuptake inhibitors and renal function.
• Recommended definitive antibiotic therapy after cultures results
For patients with HAP/VAP, we suggest that antibiotic therapy be de-escalated rather than fixed. De-escalation refers to changing an empiric
broad-spectrum antibiotic regimen to a narrower antibiotic regimen by changing the antimicrobial agent or changing from combination therapy
to monotherapy. In contrast, fixed antibiotic therapy refers to maintaining a broad-spectrum antibiotic regimen until therapy is completed
Causative pathogen Definitive antimicrobial therapy
Pseudomonas (Low risk of death (mortality risk <15%) or if septic shock
resolved)
Single susceptible Antipseudomonal agent
Pseudomonas (Septic shock or at high risk of death mortality risk >25%) Combination of two susceptible Antipseudomonal agents
Acinetobacter Species Carbapenem or ampicillin sulbactam if the isolate is susceptible to these
agents
Do not use Tigecycline
References 2016 Guidelines of Infectious diseases society of America (IDSA) and the American thoracic society
John Hopkins antibiotic guide

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Ventilator- Associated Pneumonia (VAP)
Definition Pneumonia occurring >48 hours after endotracheal intubation.
Causative organisms S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli
Duration of therapy 7 days
Therapy notes Extended infusion method of B lactams (Piperacillin-tazobactam, Cefepime, Imipenem, Meropenem) is recommended
• Recommended initial empiric antibiotic therapy
Standard Regimen Obtain sputum and blood culture
Start single Antipseudomonal antibiotic
OR Levofloxacin (750 mg IV once daily)
Pseudomonas Coverage
• Patients in units where >10% of gram-negative isolates are resistant
to an agent being considered for monotherapy
• Patients in an ICU where local antimicrobial susceptibility rates are
not available
• Risk factors for pseudomonas:
Structural lung disease (ie, bronchiectasis or cystic fibrosis)
• Risk factors for MDR:
Septic shock at time of VAP
Acute respiratory distress syndrome preceding VAP
Five or more days of hospitalization prior to the occurrence of VAP
Acute renal replacement therapy prior to VAP onset
Obtain sputum and blood culture
Combine two antipseudomonal antibiotics from different classes
Beta lactam Antipseudomonal:
OR Ceftazidime (2 g every 8 h)
OR Aztreonam (2g IV every 8 h) (In case of B lactam allergy)
PLUS
Non-Beta lactam Antipseudomonal
Levofloxacin (750 mg IV once daily)
OR Ciprofloxacin (400 mg IV every 8 h)
OR Gentamicin (5–7 mg/kg IV once) (avoided if alternatives available)

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MRSA coverage
• Patients being treated in units where >10%–20% of S. aureus
isolates are methicillin resistant
• Patients in units where the prevalence of MRSA is not known
• Risk factors for MRSA:
• Risk factors for MDR:
Septic shock at time of VAP
ARDS preceding VAP
Five or more days of hospitalization prior to the occurrence of VAP
Acute renal replacement therapy prior to VAP onset
Add to either of the preceding regimens:
Vancomycin (15 mg/kg IV every 8–12h, based on actual body weight)
Consider a loading dose of 25–30 mg/kg for severe illness to rapidly achieve
target concentrations, the initiation of the maintenance dose should occur at
the next dosing interval.
OR Linezolid (600 mg IV every 12h)
The choice between vancomycin and linezolid may be guided by patient-
specific factors such as blood cell counts, concurrent prescriptions for
serotonin-reuptake inhibitors and renal function.
• Recommended definitive antibiotic therapy after cultures results
For patients with HAP/VAP, we suggest that antibiotic therapy be de-escalated rather than fixed. De-escalation refers to changing an empiric
broad-spectrum antibiotic regimen to a narrower antibiotic regimen by changing the antimicrobial agent or changing from combination therapy
to monotherapy. In contrast, fixed antibiotic therapy refers to maintaining a broad-spectrum antibiotic regimen until therapy is completed
Causative pathogen Antimicrobial therapy
Pseudomonas (Low risk of death (mortality risk <15%) or if septic shock
resolved)
Single susceptible Antipseudomonal agent
Pseudomonas (Septic shock or at high risk of death mortality risk >25%) Combination of two susceptible Antipseudomonal agents
Acinetobacter Species Carbapenem or ampicillin sulbactam if the isolate is susceptible to these
agents
Do not use Tigecycline
References 2016 Guidelines of Infectious diseases society of America (IDSA) and the American thoracic society
John Hopkins antibiotic guide

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Aspiration Pneumonia
Definition Aspiration pneumonia refers to adverse pulmonary consequences due to entry of gastric or oropharyngeal fluids, which may contain bacteria
Causative
organisms
Anaerobic bacteria were historically believed to be the dominant organisms in aspiration pneumonia and its sequelae (lung abscess and
empyema), but subsequent studies have found that aerobic bacteria may be more prevalent, particularly in patients without abscess formation.
Predisposing
conditions
Reduced consciousness, Dysphagia from neurologic deficits, Disorders of the upper GIT including esophageal disease, surgery involving the upper
airways or esophagus, and gastric reflux, Mechanical disruption of the glottic closure or lower esophageal sphincter due to tracheostomy,
endotracheal intubation, head and neck cancer and nasogastric feeding, Pharyngeal anesthesia, miscellaneous conditions such as protracted
vomiting, large volume tube feedings, feeding gastrostomy, the recumbent position, Poor dental hygiene, Increasing age and Cardiac arrest.
There is an association between use of acid-suppressive medications and aspiration pneumonia. The loss of the gastric acid barrier results in a
higher bacterial load in gastric contents and thus in the lungs when aspiration of gastric contents occurs.
Treatment
notes
Patients with an observed aspiration should have immediate oropharyngeal suctioning with the head turned to the side to prevent further
aspiration, and those with an endotracheal tube in place should have immediate tracheal suctioning to clear fluids and particulate matter that
may cause obstruction. The chemical injury that occurs with a gastric acid aspiration event occurs instantly. Bronchoalveolar lavage, which may
be used to clear particulate matter, will not protect the lungs from the chemical injury that is already in progress.
Antimicrobial treatment
.
References UpToDate, John Hopkins antibiotic guide
Community acquired aspiration pneumonia
Non severe Ampicillin/Sulbactam 3g IV q 6 h Alternative: Ceftriaxone 2 g q 24 h Plus Metronidazole 500 mg
Severe Piperacillin- Tazobactam 3.375 gm IV q 6h
Imipenem 500 mg-1 gm IV q 6h
Meropenem 1g q 8 h
Hospital acquired aspiration pneumonia
Aerobic bacteria, especially gram-negative bacilli and S. aureus, are generally more important than anaerobes.
Standard regimen Refer to Hospital acquired Pneumonia (HAP)
Coverage for
anaerobes
Risk factors Antimicrobial agent
Patients with frank aspiration
Poor dentition
Concomitant lung abscess or empyema
Persistent clinical deterioration despite aerobic treatment
Imipenem 500 mg-1 gm IV q 6h
Meropenem 1g q 8 h
Piperacillin- Tazobactam 3.375 gm IV q 6h
Consider MRSA risk

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Urinary Tract Infections
Asymptomatic bacteriuria (ABU)
Definition Urinary growth of bacteria in an asymptomatic individual (asymptomatic bacteriuria - ABU), and corresponds to a commensal
colonization.
Clinical notes Clinical studies have shown that ABU may protect against superinfecting symptomatic UTI.
Asymptomatic bacteriuria is defined by a mid-stream sample of urine showing bacterial growth > 105
cfu/mL in two consecutive
samples in women and in one single sample in men.
Do not use pyuria as sole indicator for treatment of UTI.
In a single catheterized sample, bacterial growth may be as low as 102
cfu/mL to be considered representing true bacteriuria in both
men and women
Treatment of asymptomatic bacteriuria is harmful in patients with recurrent urinary tract infections.
Treatment Treatment of asymptomatic bacteriuria is beneficial prior to urological procedures breaching the mucosa and pregnant women.
References European Association of Urology 2023

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Uncomplicated Cystitis
Definition Acute, sporadic or recurrent cystitis limited to non-pregnant women with no known relevant anatomical and functional
abnormalities within the urinary tract or comorbidities.
Causative organism The majority of cases of uncomplicated cystitis are caused by E. coli.
Diagnostic notes The diagnosis is based on a focused history of lower urinary tract symptoms (dysuria, frequency and urgency) and the absence of
vaginal discharge.
In elderly women genitourinary symptoms are not necessarily related to cystitis
When to obtain
cultures?
Taking a urine culture is recommended in patients with atypical symptoms, as well as those who fail to respond to appropriate
antimicrobial therapy or recur within four weeks after completion of treatment
• Suggested regimens for antimicrobial therapy in uncomplicated cystitis:
• Aminopenicillins in combination with a beta-lactamase inhibitor such as ampicillin/sulbactam or amoxicillin/clavulanic acid and oral cephalosporins are
not recommended for empirical therapy due to ecological collateral damage, but may be used in selected cases.
• Fluoroquinolone should only be used when it is considered inappropriate to use other antibacterial agents that are commonly recommended for the
treatment of these infections due to their disabling and potentially long-lasting side effects
Antimicrobial Daily dose Duration Comments
First line for women
Fosfomycin 3 gm SD 1 day Recommended only in women with complicated cystitis
Nitrofurantoin macrocrystal (Macrofuran) 50-100 mg four times per
day
5 days
Nitrofurantoin monohydrate/microcrystal
(Uvamin retard)
100 mg twice daily 5 days
Alternatives
Cefadroxil 500 mg twice daily 3 days Or comparable
If the local resistance pattern for E. coli is < 20%
Trimethoprim/sulfamethoxazole 160/800 mg twice daily 3 days Not in the last trimester of pregnancy
Treatment in men
Trimethoprim/sulfamethoxazole 160/800 mg twice daily 7 days Fluoroquinolones can also be prescribed

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Recurrent urinary tract infection (rUTI)
Definition Recurrent UTIs (rUTIs) are recurrences of uncomplicated and/or complicated UTIs, with a frequency of at least three UTIs/year or
two UTIs in the last six months. Although rUTIs include both lower tract infection (cystitis) and upper tract infection
(pyelonephritis), repeated pyelonephritis should prompt consideration of a complicated etiology.
Age-related associations
of rUTI in women Young and pre-menopausal women Post-menopausal and elderly women
• Sexual intercourse with use of spermicide
• A new sexual partner
• A mother with a history of UTI
• History of UTI during childhood
• Blood group antigen secretory status
• History of UTI before menopause
• Urinary incontinence
• Atrophic vaginitis due to estrogen deficiency
• Cystocele Increased post-void urine volume
• Blood group antigen secretory status
• Urine catheterization and functional status
• deterioration in elderly institutionalized women
Behavioral changes Women with rUTI should be counselled on avoidance of risks (e.g., insufficient drinking, habitual and postcoital delayed urination,
wiping from back to front after defecation, douching and wearing occlusive underwear) before initiation of long-term prophylactic
drug treatment.
Clinical notes Initial diagnosis of rUTI should be confirmed by urine culture.
Antimicrobials may be given as continuous low-dose prophylaxis for longer periods, or as post-coital prophylaxis.
There is no significant difference in the efficacy of the two approaches.
Treatment duration Three to twelve months
Self-diagnosis and self-treatment in patients with good compliance with a short course regimen of an antimicrobial agent should be considered
Antimicrobials for preventing rUTI
Antibiotic Dose Comments
Nitrofurantoin 50-100 mg once daily
Fosfomycin trometamol 3 gm every ten days
Trimethoprim 100 mg once daily
Cefalexin 125 mg or 250 mg once daily During pregnancy
Cefaclor 250 mg once daily

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Uncomplicated pyelonephritis
Definition • Pyelonephritis limited to non-pregnant, pre-menopausal women with no known relevant urological abnormalities or comorbidities.
• Pyelonephritis is suggested by fever (> 38°C), chills, flank pain, nausea, vomiting, or costovertebral angle tenderness, with or without the
typical symptoms of cystitis
Clinical notes • Urinalysis including the assessment of white and red blood cells and nitrite is recommended for routine diagnosis. In addition, urine culture
and antimicrobial susceptibility testing should be performed in all cases of pyelonephritis.
• Additional investigations, such as a contrast enhanced computed tomography (CT) scan, or excretory urography should be considered if the
patient remains febrile after 72 hours of treatment, or immediately if there is deterioration in clinical status.
• Patients initially treated with parenteral therapy who improve clinically and can tolerate oral fluids may transition to oral therapy.
Suggested regimens for empirical oral antimicrobial therapy in uncomplicated pyelonephritis
Antimicrobial Daily dose Duration of therapy Comments
Ciprofloxacin 500-750 mg twice daily 7 days Fluoroquinolone resistance should be less than 10%.
Levofloxacin 750 mg once daily 5 days
Trimethoprim/
sulfamethoxazole
160/800 mg twice daily 14 days If such agents are used empirically, an initial intravenous dose of a long-acting
parenteral antimicrobial (e.g., ceftriaxone) should be administered.
Cefpodoxime 200 mg twice daily 10 days
Suggested regimens for empirical parenteral antimicrobial therapy in uncomplicated pyelonephritis
Antimicrobials Daily dose Comments
First line therapy
Ciprofloxacin 400 mg twice daily
Levofloxacin Levofloxacin 750 mg once daily
Cefotaxime 2 gm three times daily Not studied as monotherapy in acute uncomplicated pyelonephritis
Ceftriaxone 1-2 gm once daily Lower dose studied, but higher dose recommended.
Second line therapy
Cefepime 1-2 gm twice daily Lower dose studied, but higher dose recommended
Piperacillin /tazobactam 2.5-4.5 gm three times daily
Gentamicin 5 mg/ kg once daily Not studied as monotherapy in acute uncomplicated pyelonephritis

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Last line alternatives
Imipenem /cilastatin 500 mg four times daily Consider only in patients with early culture results indicating the presence of
multi-drug resistant organisms.
Meropenem 1 gm three times daily

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Complicated urinary tract infection
Risk factors Obstruction at any site in the urinary tract
Foreign body
Incomplete voiding
Vesicoureteral reflux
Recent history of instrumentation
Isolated ESBL-producing organisms
UTI in males
Pregnancy
Diabetes mellitus
Immunosuppression
Healthcare-associated infections
Isolated multi-drug resistant organisms
Causative organism E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp. and Enterococcus spp.
Clinical notes A cUTI is associated with clinical symptoms (e.g., dysuria, urgency, frequency, flank pain, costovertebral angle tenderness, suprapubic
pain and fever), although in some clinical situations the symptoms may be atypical for example, in neuropathic bladder disturbances,
CA-UTI or patients who have undergone radical cystectomy with urinary diversion.
Laboratory urine culture is the recommended method to determine the presence or absence of clinically significant bacteriuria.
Appropriate management of the urological abnormality or the underlying complicating factor is mandatory.
Duration Treatment for 7-14 days, is generally recommended.
Antimicrobials Daily dose Comments
If the patient mild to moderately ill (not requiring hospitalization)
Levofloxacin 750 mg once daily IV/PO for 5 days Fluoroquinolones is reasonable empiric choices if
1-Resistance rate less than 20 %
2- Not receive them in the past 6 months
3- Patient has anaphylaxis to beta lactam antimicrobials
Ciprofloxacin 500 mg PO twice daily or
400 mg /8-12 hr.
Trimethoprim/sulfamethoxazole 160/800 mg twice daily An initial intravenous dose of a long-acting parenteral antimicrobial (e.g.,
ceftriaxone) should be administered.
In case of systemic symptoms (requiring hospitalization) In case of multi drug resistant
Ceftriaxone 1 gm once daily Meropenem 1 gm /8 hrs
Amoxicillin or 2nd generation
cephalosporin + Gentamycin
500 mg/8hrs +
5 mg/kg once daily
Piperacillin/tazobactam +/-
aminoglycoside (gentamycin)
3.375 gm / 6 hrs.
5 mg/kg once daily
Imipenem /cilastatin 500 mg /6 hrs

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Catheter-associated UTIs (CA-UTI)
Definition Catheter-associated UTI refers to UTIs occurring in a person whose urinary tract is currently catheterized or has been catheterized within the
past 48 hours.
Signs and systemic symptoms compatible with CA-UTI include new onset or worsening of fever, rigors, altered mental status, malaise, or
lethargy with no other identified cause.
Clinical notes Microbiologically, CA-UTI is defined by microbial growth of > 103
cfu/mL of one or more bacterial species in a single catheter urine specimen or
in a mid-stream voided urine specimen from a patient whose urethral, suprapubic, or condom catheter has been removed within the previous
48 hours
Do not carry out routine urine culture in asymptomatic catheterized patients.
Do not use pyuria as sole indicator for catheter-associated UTI.
Do not use the presence or absence of odorous or cloudy urine alone to differentiate catheter-associated asymptomatic bacteriuria from
catheter-associated UTI.
The urine culture should be obtained from the freshly placed catheter prior to the initiation of antimicrobial therapy.
If an indwelling catheter has been in place for two weeks at the onset of CA-UTI and is still indicated, the catheter should be replaced to hasten
resolution of symptoms and to reduce the risk of subsequent CA-bacteriuria and CA-UTI.
Duration 7 days is recommended for patients with CA-UTI who have prompt resolution of symptoms.
14 days of treatment is recommended for those with a delayed response, regardless of whether the patient remains catheterized or not
A three-day antimicrobial regimen may be considered for women aged < 65 years who develop CA-UTI without upper urinary tract symptoms
after an indwelling catheter has been removed.
Treatment regimen for CA-UTI
In patients with CA-UTI who are not severely ill A five-day regimen of levofloxacin may be considered
Symptomatic catheter-associated-UTI Treat according to the recommendations for complicated UTI

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Urosepsis
Definition Sepsis is diagnosed when clinical evidence of infection is accompanied by signs of systemic inflammation, presence of symptoms of
organ dysfunction and persistent hypotension associated with tissue anoxia
Urosepsis is seen in both community-acquired and healthcare associated infections. Nosocomial urosepsis may be reduced by
measures used to prevent nosocomial infection, e.g., reduction of hospital stay, early removal of indwelling urinary catheters,
avoidance of unnecessary urethral catheterization, correct use of closed catheter systems, and attention to simple daily aseptic
techniques to avoid cross-infection.
Clinical notes Perform the quick SOFA score to identify patients with potential sepsis.
Take a urine culture and two sets of blood cultures before starting antimicrobial treatment.
Administer parenteral high dose broad spectrum antimicrobials within the first hour after clinical assumption of sepsis.
Adapt initial empiric antimicrobial therapy on the basis of culture results.
Initiate source control including removal of foreign bodies, decompression of obstruction and drainage of abscesses in the urinary
tract.
Provide immediate adequate life-support measures.
Suggested regimens for antimicrobial therapy for urosepsis.
Antimicrobials Daily dose Duration of therapy
Cefotaxime 2 gm three times daily 7-10 days
Longer courses are appropriate in patients who have a
slow clinical response
Ceftazidime 1-2 gm three times daily
Ceftriaxone 1-2 gm once daily
Cefepime 2 gm twice daily
Piperacillin/tazobactam 4.5 gm tjree times daily
Gentamicin 5 mg / kg once daily
Imipenem/cilastatin 500 mg three times daily
Meropenem 1 gm three times daily

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Sepsis
Definition Life-threatening organ dysfunction caused by a dysregulated host response to infection.
Treatment plan Prompt identification (through initial history, physical examination, and preliminary laboratory findings and imaging) and treatment
of the source of infection is the primary therapeutic intervention, with most other interventions being purely supportive
Treatment is done through:
• Eradication with empiric antibiotics
• Source control (In case of closed-space infections).
Source Control It is recommended be done as soon as possible following initial resuscitation.
Without adequate source control, many severe presentations will not stabilize or improve despite rapid resuscitation and
appropriate antimicrobials. thus, prolonged efforts at medical stabilization without source control for severely ill patients,
particularly those with septic shock, are generally not advised
Time Frame 6 to 12 hours
Source control is indicated in:
• Intra-abdominal abscesses
• Gastrointestinal perforation
• Ischemic bowel or volvulus
• Cholangitis
• Cholecystitis
• Pyelonephritis associated with obstruction or abscess
• Necrotizing soft tissue infection
• Other deep space infection (e.g., empyema or septic arthritis)
• Implanted device infections.
Source control may include:
• Drainage of an abscess
• Debriding infected necrotic tissue
• Removal of a potentially infected device
• Definitive control of a source of ongoing microbial contamination.
• Open surgical intervention should be considered when other interventional approaches are inadequate or cannot be
provided in a timely fashion.

24 | P a g e
• Surgical exploration may also be indicated when diagnostic uncertainty persists despite radiologic evaluation, when the
probability of success with a percutaneous procedure is uncertain, or when the undesirable effects of a failed procedure are
high
N.B
Prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has
been established and following successful initial resuscitation is recommended. In the absence of septic shock or fungemia, some
implanted tunneled catheter infections may be treated effectively with prolonged antimicrobial therapy if removal of the catheter is
not practical. However, catheter removal with adequate antimicrobial therapy is definitive and is the preferred treatment in most
cases
Timing of antibiotics Early administration of appropriate antimicrobials is one of the most effective interventions to reduce mortality.
For adults with possible septic shock or a high likelihood for sepsis, we recommend administering antimicrobials immediately,
ideally within one hour of recognition.
For adults with possible sepsis without shock, we suggest a time-limited course of rapid investigation and if concern for infection
persists, the administration of antimicrobials within 3 hours from the time when sepsis was first recognized.
When to obtain
cultures?
Microbiologic cultures (including blood) should be obtained before starting antimicrobial therapy in patients with suspected sepsis
and septic shock if it results in no substantial delay in the start of antimicrobials (i.e., < 45min).
De-escalation of
Antibiotics
Daily assessment for de-escalation of antimicrobials is recommended over using fixed durations of therapy without daily
reassessment for de-escalation.
Once both the pathogen(s) and susceptibilities are known, antimicrobial de-escalation−i.e., stopping an antimicrobial that is no
longer necessary (in case of combination therapy) or changing an antimicrobial to narrow the spectrum is encouraged.
Early discontinuation of all antimicrobial therapy if infection is ruled out is advisable.
Antimicrobial de-escalation should ideally be done as soon as possible,
De-escalation is in generally safe, may offer cost savings when unnecessary antibiotics are discontinued, and reduced risk of
antimicrobial resistance and reduced toxicity and side-effects may be important.
Duration 7 to 10 days
Longer courses are appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with
S. aureus, some fungal and viral infections, or immunologic deficiencies, including neutropenia.
For adults with adequate source control, using shorter over longer duration of antimicrobial therapy is recommended as this is less
costly, has fewer undesirable effects without impacting adversely on outcomes.
The shorter course was just as effective as the longer course but associated with fewer adverse consequence.
Biomarkers Use procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone.
C-reactive protein is often used too

25 | P a g e
Antimicrobial empirical treatment:
1. If the source is unknown
Empiric broad-spectrum therapy with one or more antimicrobials for patients to cover all likely pathogens (including bacterial and potentially
fungal coverage) until cultures results then empiric antimicrobial therapy must be narrowed once pathogen identification and sensitivities are
established and/or adequate clinical improvement is noted.
Empirical
regimen
Risk factors Antibiotic choice
Standard
Regimen
Low risk for MRSA and MDR pathogens Single gram-negative agent (B lactams are preferred)
Extended or Continuous infusion method are preferred (See
(Extended or Continuous infusion method)
Ceftriaxone (1-2 g every 12 hours)
OR Cefotaxime (2g every 6 hours)
OR Ceftazidime (2g every 8 hours)
OR Cefepime (2g every 8 hours)
OR Piperacillin-tazobactam (4.5 g every 6 hours)
OR Imipenem (500 mg every 6 hours or 1 g every 8 hours)
OR Meropenem (1 g every 8 hours)
B lactam allergy Aztreonam (2g every 8 hours)
MDR pathogens
coverage
For High risk for multidrug resistant (MDR) organisms:
• Proven infection or colonization with antibiotic-resistant
organisms within the preceding year.
• Septic shock.
• Local prevalence of antibiotic-resistant organisms.
• Hospital-acquired/healthcare−associated (versus community-
acquired infection).
• Broad-spectrum antibiotic use within the preceding 90 days.
• Concurrent use selective digestive decontamination (SDD).
• Prolonged/prior hospitalization
• Travel to a highly endemic country within the preceding 90
days.
Use two antimicrobials with gram-negative coverage from two
different groups
Combine one agent from standard regimen with one agent
from:
Antipseudomonal fluoroquinolone:
Ciprofloxacin (400 mg every 8 hours)
Levofloxacin (750 mg every 24 hours)
OR
Antipseudomonal Aminoglycoside:
Gentamicin (5–7 mg/kg once daily) *

26 | P a g e
In patients with low risk for MDR organisms, only one gram-negative
agent should be used.
Once the causative pathogen and the susceptibilities are known,
only one gram-negative agent should be used except for patients
with highly resistant organisms.
MRSA coverage Accounts for only 5% of cultures
Empiric treatment for MRSA is only recommended for patients with
high risk for MRSA.
Patient-related risk factors for MRSA
• Prior history of MRSA infection or colonization
• Recent IV antibiotics
• History of recurrent skin infections or chronic wounds
• Presence of invasive devices
• Hemodialysis
• Recent hospital admissions
• Severity of illness
Unnecessary MRSA coverage in a patient without MRSA can be harmful.
Early discontinuation of MRSA coverage is accompanied by better
outcomes in patients with negative cultures.
Vancomycin (15 mg/kg IV every 8–12h, based on actual body
weight)
Consider a loading dose of 25–30 mg/kg for severe illness to
rapidly achieve target concentrations, the initiation of the
maintenance dose should occur at the next dosing interval.
OR
Linezolid (600 mg IV every 12h)
Considered in refractory or virulent MRSA or with a
contraindication to vancomycin.
A significant risk
of Legionella
Add a macrolide or fluoroquinolone
B lactams are not effective
Fungal coverage The decision to start empiric antifungal therapy depends on the type
and number of risk factors, along with the local epidemiology of fungal
infections.
Risk factors for fungi:
• Candida Colonization at Multiple Sites
• Neutropenia
• Immunosuppression
• Severity of Illness (High APACHE score)
• Longer ICU Length of Stay
• Central Venous Catheters and Other Intravascular Devices
Persons Who Inject Drugs
Echinocandin (anidulafungin, micafungin, or caspofungin) is
preferred in most patients with severe illness, especially in septic
shock, who have recently been treated with other antifungal
agents, or if Candida glabrata or Candida krusei infection is
suspected from earlier culture data.
Liposomal formulations of amphotericin B are a reasonable
alternative to echinocandins in patients with echinocandin
intolerance or toxicity
Triazoles are acceptable in hemodynamically stable,

27 | P a g e
• Total Parenteral Nutrition
• Prolonged broad spectrum antibiotics administration
• Gastrointestinal Tract Perforations and Anastomotic Leaks
Emergency Gastrointestinal or Hepatobiliary Surgery
• Acute Renal Failure and Hemodialysis
• Prior Surgery
• Chemotherapy
• Chronic liver failure
• Diabetes Mellitus
• Solid Organ Transplantation
• High Dose Corticosteroid Therapy
less ill patients who have not had previous triazole exposure and
are not known to be colonized with azole-resistant species.
Fluconazole (IV/Oral): Loading dose of 800 mg (or 12 mg/kg) on
day 1, then 400 mg (or 6 mg/kg) once daily.
Viral coverage Apart from specific clinical situations such as epidemics/pandemic,
viruses are rarely the primary cause of sepsis. It is unclear to what
extent the primary viral infection as opposed to bacterial pneumonia
co-infection is the cause of organ dysfunction in these patients.
Antiviral therapy in sepsis is not recommended.
*Once-daily dosing yields at least comparable clinical efficacy with possibly decreased renal toxicity compared to multiple daily dosing regimens. Once-daily dosing of aminoglycosides is used for
patients with preserved renal function. Patients with chronically mildly impaired renal function should still receive a once-daily-equivalent dose but would normally have an extended period (up to 3
days) before the next dose. This dosing regimen should not be used in patients with severe renal function in whom the aminoglycoside is not expected to clear within several days.
Gentamicin should not be used as monotherapy for severe infections outside of the urinary tract
2. If source is identified:
Treat according to disease guidelines
Source Treatment
Intra-abdominal focus
(See Intra-abdominal
infections)
Monotherapy Combination therapy
Piperacillin/tazobactam (4.5 g every 6 hours)
Imipenem (500 mg every 6 hours or 1 g every 8 hours)
Meropenem (1 g every 8 hours)
Cefepime (2g every 8 hours)
Ceftazidime (2g every 8 hours)
Ciprofloxacin (400 mg every 8 hours)
Each in combination with metronidazole (500 mg every 8 hours)
Consider anti-fungal therapy in selected patients, especially if prior exposure to antibiotic or recent GI surgery)
Skin and soft tissue (See Skin and Soft tissues infections)
Pneumonia (See Pneumonia)
Urinary tract infection (See Urosepsis)

28 | P a g e
Extended or Continuous infusion method
Antibiotics are subject to changes in pharmacokinetics and pharmacodynamics parameters in severe illness where resultant concentrations may
be too low risking clinical failure, or too high leading to toxicity.
Augmented renal clearance, AKI, hypoalbuminemia, RRT, and extracorporeal membrane oxygenation are examples of common scenarios that
affect the concentrations of some antibiotics.
Prolonged infusion (Extended or Continuous) of beta-lactams (after an initial bolus) is recommended over conventional bolus infusion in severe
illnesses.
Beta-lactam antibiotics may be subject to changes in important pharmacokinetic parameters in the setting of sepsis and septic shock: increased
volume of distribution for most antimicrobials, in part due to the rapid expansion of extracellular volume as a consequence of aggressive fluid
resuscitation resulting in sub-therapeutic concentrations.
As opposed to conventional intermittent infusion (infusion ≤ 30 minutes), administration by prolonged IV infusion, either as an extended
infusion (antibiotic infused over at least half of the dosing interval) or as a continuous infusion, results in sustained beta-lactam concentrations
which align with the pharmacodynamics of these drugs.
Administration of a loading dose of antibiotic before prolonged infusion is essential to avoid delays to achieving effective beta-lactam
concentrations.
Over the course of therapy, both extended and continuous infusions will occupy a venous catheter/lumen more than an intermittent infusion
and drug-stability and drug-drug compatibility considerations are important to ensure effectiveness of antibiotic and other IV drug therapies
The reduction in short-term mortality from prolonged infusion of beta-lactams is significant with the intervention being feasible with negligible
cost implications and no data suggesting inferior outcomes with prolonged infusion
Antibiotic Dose Interval Infusion time
Piperacillin-tazobactam 3.375 or 4.5 g Every 8 hours 4 hours
Cefepime 2 g Every 8 hours 3 to 4 hours
Imipenem 500 mg or 1 g Every 6 hours 3 hours
Meropenem 1 or 2 g Every 8 hours 3 hours
References Surviving sepsis campaign 2016: International guidelines for management of sepsis
Surviving sepsis campaign 2021
UpToDate
John Hopkin’s antibiotic guide

29 | P a g e
Intra-abdominal infections
Introduction Table (1)
Common causative
pathogens:
What about MRSA? What about Candida? What about Enterococcus? What about ESBL producing
bacteria?
• Gram negative
Enterobacteriaceae
• Gram positive
streptococci
• Obligate anaerobes
• Empiric MRSA coverage
is generally not
recommended
• Empiric MRSA coverage
with the addition of
Vancomycin IV may be
considered for hospital
acquired infection with
known MRSA
colonization or invasive
infection within the past
year1 and should be
discontinued at 48 hours
if MRSA is not recovered
from cultures.
• Empiric Candida
coverage is not
recommended
• Empiric antifungal
coverage is appropriate
for patients at risk for
infection with Candida
spp, including those with
upper gastrointestinal
perforations, recurrent
bowel perforations,
surgically treated
pancreatitis, heavy
colonization with
Candida spp, and/or
yeast identified on Gram
stain of samples from
infected peritoneal fluid
or tissue Fluconazole can
be used for patients who
are not severely ill and
have no history of
infection with a
fluconazole-resistant
isolate; otherwise, an
echinocandin can be
used.
• Empiric coverage for E
faecalis is only
recommended for high-
risk patients with at least
one risk factor.
• Risk factors include
hospital-acquired
infection, post-operative
infection, recent
cephalosporin use, and
immunocompromised
state. Consider empiric
VRE coverage in septic or
severely ill patients with
prior known colonization
or invasive infection.
• In cases where a patient has
a history of colonization with
ESBL Enterobacteriaceae
within the past year,
recommend use of
ertapenem in lieu of
piperacillin/tazobactam
• The main risk factors for
ESBL are: hospitalization for
48h within the last 90 days,
broad-spectrum antibiotics
for 5 days within the last 90
days, colonization by ESBL
within 90 days.

30 | P a g e
Risk factors that warrant broad spectrum antimicrobial coverage in high-risk severe community-acquired and
health-care-associated intra-abdominal infections
Table (2)
Table (3)
Factors associated with infection with antibiotic-resistant bacteria
Health care-acquired infection (>48 hours into hospitalization)
travel to areas with higher rates of antibiotic-resistant organisms* within the few weeks prior to infection onset or if antibiotics were
received during travel
Known colonization with antibiotic-resistant organisms
Hospitalization within past 90 days
Broad-spectrum antibiotic use within past 90 days
History of resistant organisms within past year
References IDSA 2010
UpToDate
John Hopkins
WSES/GAIS/SIS-E/WSIS/AAST 2021
Factors associated with severe infections and high mortality risk
Age >70 years
Medical comorbidity (e.g., renal or liver disease, presence of malignancy, chronic malnutrition)
Immunocompromising condition (e.g., poorly controlled diabetes mellitus, chronic high-dose corticosteroid use, use of other
immunosuppressive agents, neutropenia, advanced HIV infection, B or T leukocyte deficiency)
High severity of illness (i.e., sepsis)
Extensive peritoneal involvement or diffuse peritonitis
Delay in initial intervention (source control) >24 hours
Inability to achieve adequate debridement or drainage control

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Acute cholecystitis
Definition Acute cholecystitis is a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation.
It typically occurs in patients with gallstones (ie, acute calculous cholecystitis [ACC]), while acalculous cholecystitis without gallstones accounts
for a minority (5 to 10 percent) of cases.
Complications of acute cholecystitis include gallbladder gangrene or perforation, which can be life-threatening.
Causative
pathogens
Gram negative: E. coli, Klebsiella, Enterobacter sp., pseudomonas.
Gram positive: Enterococcus.
Anaerobes: Clostridium and Bacteroides.
Antibiotic
therapy notes
• Initially all patients should receive antimicrobial therapy.
• Early laparoscopic surgery is preferred treatment.
• some Poor surgical candidates may benefit from initial nonoperative management with antibiotics and a gallbladder drainage procedure;
those whose surgical risk improves after resolution of the acute inflammation should undergo elective gallbladder surgery to prevent
recurrent symptoms.
• Persistent fever, abnormal vital signs or illness following cholecystectomy indicates a potential complication or need for further
antimicrobial therapy that should be extended accordingly.
Duration of
antibiotics
When Cholecystectomy is performed
• If no infection outside of the wall of gallbladder: Stop antibiotics within 24h of surgery.
• If infection outside wall of gallbladder: 4 to 7days (inclusive IV and ORAL therapy) after surgery with adequate source control and
clinical signs resolution.
In patients with initial nonoperative management with antibiotics
• Use until clinical resolution.
Oral step-
down therapy
An intravenous regimen can be transitioned to an oral regimen once the patient has demonstrated clinical improvement.
Levofloxacin 750mg po once daily + metronidazole 500mg three times daily.
Ciprofloxacin 500 mg po twice daily + metronidazole 500mg three times daily.
Amoxicillin-clavulanate 875/125 mg two to three times daily (use with caution in high-risk patients with MDR-GNR risk factors).

32 | P a g e
* To provide enterococcal coverage in particularly those with postoperative infection, those who have previously received cephalosporins or other
antimicrobial agents selecting for Enterococcus species, immunocompromised patients, and those with valvular heart disease or prosthetic intravascular
materials
(A) Mild to moderate Low-risk community-acquired acute cholecystitis (Who have no risk factors for antibiotic resistance or treatment failure)
Primary Alternatives
(Addition of metronidazole is not necessary except if biliary enteric anastomosis
presents)
Preferred to reserve for more
resistant infections
Piperacillin-tazobactam 3.375 g
IVq6hr /4.5g IVq8hr
Cefazolin 1 to 2 g IVq8hr Ciprofloxacin 400 mg IVq12hr Ertapenem 1g IV once daily
Ceftriaxone 2 g IV once daily Levofloxacin 750 mg IV once daily
Cefotaxime2 g IVq8hr
(B) High-risk community-acquired acute cholecystitis (in severe cases or in patients at high risk of adverse out comes or resistance) (See table 2)
Combination regimen Only if (Beta lactam or carbapenem allergy)
Imipenem- cilastatin 500 mg IVq6hr Cefepime 2 g IVq8hr Aztreonam 1-2gm IVq8hr Plus,
Vancomycin 15 to 20 mg/kg IVq8 to 12 hours Plus,
Metronidazole500 mg IVq8hr
Meropenem 1 g IVq8hr Ceftazidime 2 g IVq8hr
Piperacillin-tazobactam4.5 g IVq6hr PLUS, Metronidazole 500 mg IVq8hr
(C) Health-care-associated acute cholecystitis (For patients with health care-associated infections, the likelihood of drug resistance is high) (See table 3)
We also usually use an empiric regimen that has anti-enterococcal activity.
Imipenem- cilastatin 500 mg IVq6hr Cefepime2 g IVq8hr Aztreonam 1-2gm IVq8hr Plus,
Vancomycin 15 to 20 mg/kg IVq8 to 12 hours Plus
metronidazole500 mg IVq8hr
Meropenem 1 g IVq8hr Ceftazidime2 g IVq8hr
Piperacillin-tazobactam4.5 g IVq6hr Plus, metronidazole 500 mg IVq8hr
Plus, one of the following in some cases only*
Ampicillin 2 g IVq4 hours
Vancomycin15 to 20 mg/kg IVq8 to 12hr
If MRSA risk add one of the following
Vancomycin 15 to 20 mg/kg IVq8 to 12hr
Linezolid 600mgq12hr

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Acute Cholangitis
Definition Acute cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain that develops as a result of stasis and infection
in the biliary tract. It is also referred to as ascending cholangitis.
Sources of obstruction: gallstones and choledocholithiasis (50%), strictures, biliary or pancreatic malignancy, congenital malformations,
iatrogenic (occluded stent or drain)
Iatrogenic cholangitis causes include ERCP, percutaneous transhepatic cholangiography, recent cholecystectomy and biliary stents.
Causative
pathogens
E. coli (22-50%), Klebsiella species (15-20%), Enterobacter species (5-10%) Enterococcus (10-20%) and anaerobe (Bacteroides).
Antibiotic
therapy notes
• Initially all patients should receive antimicrobial therapy.
• Patients unresponsive to antibiotics may require urgent/early drainage (cholecystostomy) or surgery (gallstones) ERCP or PTD.
Duration of
antibiotics
• Antimicrobial therapy is continued for an additional duration of four to five days after adequate source control by ERCP, PTD.
• If severe bacterial infections, treat for 7-10 days (inclusive IV and oral therapy) or until clinical resolution.
Oral step-
down therapy

34 | P a g e
materials
(A) Mild to moderate Low-risk community-acquired acute cholangitis (Who have no risk factors for antibiotic resistance or treatment failure)
(Addition of metronidazole is not necessary except if biliary enteric anastomosis
presents)
Preferred to reserve for more
IVq6hr /4.5g IVq8hr
Ceftriaxone 2 g IV once daily may be
associated with biliary sludge
Levofloxacin 750 mg IV once daily
Cefotaxime 2gm IVq8hr
(B) High-risk community-acquired acute cholangitis (in severe cases or in patients at high risk of adverse out comes or resistance) (See table 2)
Combination regimen Only if Beta lactam or carbapenem allergy
Imipenem-Cilastatin 500 mg IVq6hr Cefepime2 g IVq8hr Aztreonam 1-2gm IVq8hr PLUS
Vancomycin 15 to 20 mg/kg IVq8 to 12 hours PLUS
Metronidazole 500 mg IVq8hr
Piperacillin-tazobactam4.5 g IVq6hr PLUS, Metronidazole500 mg IVq8hr
(C) Health-care-associated acute cholangitis (For patients with health care-associated infections, the likelihood of drug resistance is high) (See table 3)
We also usually use an empiric regimen that has anti-enterococcal activity
Imipenem- cilastatin 500 mg IVq6hr Cefepime2 g IVq8hr Aztreonam 1-2gm IVq8hr PLUS
metronidazole500 mg IVq8hr
Piperacillin-tazobactam4.5 g IVq6hr PLUS, metronidazole500 mg IVq8hr
PLUS, one of the following in some cases
only*

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Acute appendicitis
Definition Nonperforated appendicitis, also referred to as simple appendicitis or uncomplicated appendicitis, refers to acute appendicitis that presents
without clinical or radiographic signs of perforation.
perforated appendicitis is appendicitis with clinical or radiographic signs of perforation (e.g., inflammatory mass, phlegmon, or abscess)
sepsis/septic shock or peritonitis.
Causative
Pathogens
Enterobacteriaceae (e.g., Escherichia coli, Klebsiella spp., and Enterobacter spp.) Anaerobes (e.g., Bacteroides spp.) Gram-positive cocci (e.g.,
Enterococcus spp, Streptococcus spp).
Antibiotic
therapy
notes
• Antimicrobial therapy should be administered to all patients diagnosed with appendicitis but acute appendicitis without perforation, abscess,
or peritonitis managed by appendectomy: requires ONLY preoperative antibiotics.
• The goal standard treatment for acute appendicitis is appendectomy.
• Conservative antibiotic therapy without surgery may be a reasonable alternative in low-risk situations with selected patients but it is
associated with higher recurrence rates. Appropriate in patients without peritonitis, severe sepsis, and shock. Benefits are a shorter duration
of disability and a shorter duration of hospitalization. But Associated with a 30-40% risk of recurrence over five years. The presence of an
appendicolith is considered a relative contraindication, associated with abscess formation and a 2-fold increased risk of appendectomy
within 30 days. Age >45 is also a relative contraindication due to the higher prevalence of occult appendiceal malignancy and increased
abscess and rupture rates.
Duration
of
antibiotics
• Non-perforated appendicitis, Appendectomy performed: Discontinue post operative antibiotics within 24h of surgery.
• In uncomplicated acute appendicitis conservative only without surgery: IV antibiotics followed by oral antibiotic for up to a total of 10 to 14
days (inclusive IV and oral therapy)
• Perforated appendicitis, Surgical source control is adequate: Stop antibiotics after 4 to 5 days (inclusive IV and oral therapy)
• The duration of antibiotics for patients with perforated appendicitis who do not undergo appendectomy during the same admission varies
depending on whether percutaneous drainage is performed, as well as the patient's clinical response to treatment. Those who respond to
initial antibiotic therapy can be discharged with oral antibiotics to complete a 7 to 10 days course in total.
• Patients who have ongoing signs of infection or systemic illness beyond 5 to 7 days of antibiotic treatment warrant a diagnostic investigation.
Oral step-
down
therapy
Levofloxacin 750mg PO once daily + metronidazole 500 mg three times daily.
Ciprofloxacin 500 mg PO twice daily + metronidazole 500 mg three times daily.

36 | P a g e
materials
(A) Low-risk community-acquired uncomplicated acute appendicitis conservative only without surgery
(B) Mild to moderate low risk stable complicated appendicitis (perforated appendices or appendiceal abscesses) (Who have no risk factors for antibiotic
resistance or treatment failure)
Combination regimen Preferred to reserve for
more resistant infections
Piperacillin-tazobactam 3.375 g IVq6hr
/4.5g Ivq8hr
Cefazolin1 to 2 g Ivq8hr Ciprofloxacin 400 mg Ivq12hr Ertapenem 1g IV once daily
Cefepime2 g IVq8hr
Ceftazidime2 g IVq8hr
PLUS, Metronidazole 500 mg IVq8hr
(C) High risk or severe unstable perforated appendicitis (in patients at high risk of adverse out comes or resistance) (See Table 2)
(D) Rare cases of health-care-associated acute appendicitis (the likelihood of drug resistance is high) (See Table 3, Page
PLUS, one of the following in some cases only*

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Acute pancreatitis
Definition Acute pancreatitis can be divided into two broad categories: Interstitial edematous acute pancreatitis, which is characterized by acute
inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognizable tissue necrosis.
Necrotizing acute pancreatitis, which is inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis and is
classified into infected and sterile necrotizing pancreatitis.
According to the severity, acute pancreatitis is divided into the following:
• Mild acute pancreatitis, which is characterized by the absence of organ failure and local or systemic complications.
• Moderately severe acute pancreatitis, which is characterized by no organ failure or transient organ failure (<48 hours) and/or local
complications.
• Severe acute pancreatitis, which is characterized by persistent organ failure (>48 hours) that may involve one or multiple organs.
Causative
pathogens
Infected pancreatic necrosis: usually caused by bowel flora (gram-negative, gram-positive and anaerobic organisms).
Resistant bacterial and fungal infection may occur, especially if patients have received prior antibiotics.
Antibiotic
therapy
notes
• Prophylactic antibiotics are not recommended in patients with acute pancreatitis, regardless of the type (interstitial or necrotizing) or disease
severity (mild, moderately severe, or severe)
• The only use of antibiotics in patients with suspected infected pancreatic necrosis and not with suspected sterile necrosis as the use of
antibiotics in patients with sterile necrosis to prevent the development of infected necrosis is not recommended.
• Both sterile and infected necrosis may cause abdominal pain, fever, leukocytosis. If infection suspected, obtain CT- or U/S-guided aspirate for
Gram stain and culture, begin empiric antibiotics, and continue antibiotics if culture is positive.
• Infected necrosis should be suspected in patients with pancreatic or extra pancreatic necrosis who deteriorate (clinical instability or sepsis
physiology, increasing white blood cell count, fevers) or fail to improve after 7 to 10 days of hospitalization.
Duration
of
antibiotics
• If the aspirated material on CT-guided FNA is sterile, we discontinue antibiotics.
• In stable patients with infected necrosis, we attempt to delay necrosectomy or drainage by continuing antibiotics for at least four weeks.
• In addition, some patients with infected necrosis clinically improve to an extent that no intervention is necessary and resolution of fever,
leukocytosis, and paralytic ileus can be used to help determine the therapy length.
• If adequate source control obtained by necrosectomy or drainage, continue antibiotics for 4 days (inclusive IV and oral therapy)
Oral step-
down
therapy
Levofloxacin 750mg PO once daily + metronidazole 500mg three times daily.
Ciprofloxacin 500 mg PO twice daily + metronidazole 500mg three times daily.

38 | P a g e
* To provide enterococcal coverage in particularly those with postoperative infections, those who have previously received cephalosporins or other
materials
Suspected infected necrotizing pancreatitis (Since infection is often hospital acquired consider broad empiric coverage, antibiotics known to penetrate
pancreatic necrosis).
Combination regimen Not preferred as empirical because of
high resistance
Only if Beta lactam or carbapenem
allergy
Only if Beta lactam or carbapenem allergy
Piperacillin-tazobactam 4.5g
IVq6hr
Cefepime2 g IVq8hr Ciprofloxacin 400 mg Ivq12hr Aztreonam 1-2gm IVq8hr
PLUS
Vancomycin 15 to 20 mg/kg IVq8 to 12 hours
PLUS
Meropenem 1 g IVq8hr Ceftazidime2 g IVq8hr Levofloxacin 750 mg IV once daily
Imipenem- cilastatin 500 mg
IVq6hr
PLUS, metronidazole500 mg
IVq8hr
PLUS, Metronidazole500 mg IVq8hr
PLUS, One of the following in some
cases only*
Vancomycin15 to 20 mg/kg IVq8 to
12hr
OR Linezolid 600mgq12hr

39 | P a g e
Intra-abdominal abscess
Definition • Broad range of presenting complaints: Patients may only present with malaise/anorexia or weight loss. Others present acutely ill in septic
shock with localized pain or an acute abdomen.
• Non-visceral abscesses develop after gastrointestinal perforation from local disease (diverticulitis, etc.), trauma or surgical intervention.
Abscess is known to occur in up to 40% of cases of acute complicated diverticulitis.
• Subsequent secondary peritonitis then becomes walled off by inflammatory adhesions, loops of intestine, mesentery or omentum, and other
abdominal viscera.
• Intra-abdominal abscess may also develop after primary peritonitis (spontaneous bacterial peritonitis).
• Symptoms: fever, pain, nausea, vomiting, anorexia, leukocytosis.
• PE: local tenderness, possibly a palpable mass; if postoperative, assessment for abscess confounded by analgesics, ileus and incisional pain;
over half presenting within 10 days of initial operation.
Causative
Pathogens
• If the source of abscess is identified, location (e.g., site of perforation - stomach, duodenum, jejunum, ileum, appendix, or colon) defines likely
flora. Enterobacteriaceae (Escherichia coli, Klebsiella spp., Proteus spp., and Enterobacter spp.) and other gram-negative bacilli.
• Anaerobes, including Bacteroides spp., Fusobacterium spp., Clostridium spp., Actinomyces spp.
• Occasionally, gram-positive bacteria, including Staphylococcus aureus and Streptococci.
• Inflammatory bowel disease, particularly Crohn’s, increase the risk of intra-abdominal and anorectal abscess and increased rates of
recurrence.
• Healthcare-associated flora (Pseudomonas spp, resistant Enterobacteriaceae, Candida spp.) are more likely when infections are complications
of prior intra-abdominal operations or procedures.
Antibiotic
therapy
notes
Antimicrobial therapy alone (without drainage or a surgical procedure) should be reserved for highly-selected patients with a relatively small (< 3
cm diameter), well-circumscribed area of infection and minimal physiological derangement with follow up clinical resolution
Duration
of
antibiotics
• After adequate drainage, at least 4-5 days (inclusive IV and oral therapy) of antibiotic coverage is indicated, with duration in part based on the
resolution of fever and leukocytosis, severity of infection, and additional indicators of clinical response.
• if inadequate surgical problem or source control, a longer course of antibiotics may be appropriate with follow-up imaging to ensure
resolution.
Oral step-
down
therapy
Amoxicillin-clavulanate 875/125 mg two to three times daily (Use with caution in high-risk patients with MDR-GNR risk factors).

40 | P a g e
materials
(A) Mild to moderate Low-risk community-acquired Intra-abdominal abscess (Who have no risk factors for antibiotic resistance or treatment failure)
Combination regimen Preferred to reserve for more
IVq6hr /4.5g IVq8hr
Cefazolin1 to 2 g IVq8hr Ciprofloxacin 400 mg IVq12hr Ertapenem 1g IV once daily
PLUS, Metronidazole500 mg IVq8hr PLUS, metronidazole500 mg IVq8hr
(B) High-risk community-acquired Intra-abdominal abscess (in severe cases or in patients at high risk of adverse out comes or resistance) (See Table 2)
(C) Health-care-associated Intra-abdominal abscess (The likelihood of drug resistance is high) (See Table 3)
We also usually use an empiric regimen that has anti-enterococcal activity
Imipenem-cilastatin 500 mg IVq6hr Cefepime2 g IVq8hr Aztreonam 1-2gm IVq8hr PLUS
only*

41 | P a g e
Acute colonic diverticulitis
Definition It is classified into:
• Uncomplicated acute diverticulitis: Defined as localized diverticular inflammation without any abscess or perforation or fistula or
obstruction and the infection only involves a single organ and does not extend to the peritoneum.
• Complicated acute diverticulitis is characterized by presence of abscess or perforation or diffuse peritonitis of fistula or obstruction and the
infectious process proceeds beyond the colon.
Pathogens Polymicrobial gastrointestinal flora Anaerobes, including Bacteroides species Gram-negative bacilli, including Enterobacteriaceae Enterococcus.
Antibiotic
therapy
notes
Based upon findings from the history, physical examination, and CT scan, patients are triaged to receive either inpatient or outpatient treatment
Outpatient criteria (No antibiotics) Inpatient criteria
In patients with CT diagnosis of
uncomplicated acute diverticulitis
in healthy well immunocompetent
patients.
For patients with CT diagnosis of uncomplicated acute diverticulitis is reserved for patients with
1. Sepsis or septic shock.
2. Severe abdominal pain or diffuse peritonitis and/or failure to control abdominal pain in the
emergency department.
3. Microperforation (e.g., a few air bubbles outside the colon without contrast extravasation) or
phlegmon.
4. Age >70 years.
5. Significant comorbidities (e.g., Diabetes mellitus with organic involvement [e.g., retinopathy,
angiopathy, nephropathy], a recent cardiogenic event [e.g., acute myocardial infarction, angina, heart
failure], or recent decompensation of chronic liver disease [≥Child B] or end-stage renal disease).
6. Immunosuppression (e.g., Pregnancy, poorly controlled diabetes mellitus, chronic high-dose
corticosteroid use, use of other immunosuppressive agents, [HIV] infection, active cancer of
hematologic malignancy, or organ transplant).
7. Intolerance of oral intake secondary to bowel obstruction or ileus.
8. Failed outpatient treatment (Mild to moderate low risk regimen)
All patients with CT diagnosis of complicated acute diverticulitis
Antibiotics
duration
Outpatients treated without antibiotics who fail to improve in 2-3 days should be admitted for inpatient treatment.
Inpatients: Antibiotics should be continued for total 10-14days (inclusive of intravenous and oral antibiotic therapy)
Oral step-
down
therapy
Trimethoprim-sulfamethoxazole (1 double-strength tablet every 12 hours) plus metronidazole (500 mg every 8 hours).
Amoxicillin-clavulanate 875/125 mg two to three times daily (use with caution in high-risk patients with MDR-GNR risk factors)

42 | P a g e
materials
(A) Mild to moderate Low-risk uncomplicated acute colonic diverticulitis inpatient criteria (only patients who Failed outpatient treatment)
(A) Mild to moderate Low-risk complicated acute colonic diverticulitis inpatient criteria (Who have no risk factors for antibiotic resistance or treatment failure)
Combination regimen Preferred to reserve for more
IVq6hr /4.5g IVq8hr
PLUS, Metronidazole 500 mg IVq8hr PLUS, Metronidazole 500 mg IVq8hr
(B) High-risk uncomplicated acute colonic diverticulitis inpatient criteria (in severe cases or in patients at high risk of adverse out comes or resistance)
(B) High-risk complicated acute colonic diverticulitis inpatient criteria (in severe cases or in patients at high risk of adverse out comes or resistance)
(C) Health-care-associated acute colonic diverticulitis (In rare occasions when acute diverticulitis develops in patients who are already hospitalized or have
undergone percutaneous drainage). We also usually use an empiric regimen that has anti-enterococcal activity.
Piperacillin-tazobactam4.5 g IVq6hr PLUS, Metronidazole 500 mg IVq8hr
only*

43 | P a g e
Spontaneous bacterial peritonitis/ (SBP)
Spontaneous bacterial empyema (SBE)
Definition • Bacterial infections are present in approximately one-third of patients with cirrhosis who are hospitalized, a much higher prevalence than in
those without cirrhosis. A common yet unique type of infection in this setting is “spontaneous” infections that occur in the absence of an
obvious source of infection. These include SBP, spontaneous bacteremia, and SBE (infection of the HH). Bacterial translocation, the passage of
bacteria from the gut to the bloodstream and other extraintestinal sites, together with decreased host defenses have been implicated in the
pathogenesis of these spontaneous infections.
• The diagnosis of SBP or SBE is established with a fluid (ascites or pleural, respectively) absolute neutrophil count greater than 250/mm.
• A diagnostic paracentesis should be performed as soon as a patient with cirrhosis and ascites is hospitalized emergently for any reason, even in
the absence of symptoms suggestive of infection or whenever a patient (hospitalized or not) develops signs suggestive of infection.
• if suspected SBE when pleural effusion is present, a diagnostic thoracentesis should be performed when there is no ascites or when diagnostic
paracentesis has ruled out SBP while bacterial infection is suspected.
Causative
Pathogens
• SBP and SBE are typically mono microbial.
• Specific microorganisms are mostly enteric (with the most common being Escherichia coli, followed by Klebsiella pneumoniae, Staphylococcus
aureus, Enterococcus faecalis, and Enterococcus faecium).
• More recently, there has been a shift toward gram-positive and multidrug-resistant organisms (MDRO), particularly in nosocomial and health
care–associated SBP.
Antibiotic
therapy
notes
• Diagnostic paracentesis or thoracentesis is recommended in any patient suspected of having SBP or SBE before starting antibiotic treatment.
• IV antibiotics should be started empirically (before obtaining culture results) in all patients with an ascites PMN count >250/mm3.
• Empirical antibiotics should also be started in patients with SBE (pleural fluid PMN count >250/mm3).
• There is no need for coverage anaerobes.
• Patients with bacterascites (neutrophil count less than 250/mm3 but positive bacterial culture) exhibiting signs of systemic inflammation or
infection should be treated with antibiotics. Otherwise, the patient should undergo a second paracentesis. If the culture results come back
positive again, regardless of the neutrophil count, the patient should be treated.
Antibiotics
duration
• Duration is generally be limited to 5 to 7 days.
• Given increasing recent failure rates of initial antibiotic therapy, which may lead to increased mortality, it is recommended that a diagnostic
paracentesis (or thoracentesis for SBE) be performed 48 hours after initiating antibiotic therapy to assess response. A negative response is
defined by a decrease in PMN count <25% from baseline and should lead to broadening the antibiotic spectrum and investigating secondary
peritonitis.

44 | P a g e
Prevention of First Episode of SBP (Primary Prophylaxis)
N.B: Prophylaxis of SBE isn’t studied yet
Prevention of Recurrence (Secondary Prophylaxis)
N.B: Prophylaxis of SBE isn’t studied yet
In patients with cirrhosis and acute
active upper gastrointestinal
hemorrhage
In patients with cirrhosis without acute active upper
gastrointestinal hemorrhage
Primary
regimen
Alternatives
• The risk of SBP and other bacterial
infections is high so add:
SBP prophylaxis should be individualized based on estimated
risks and benefits with the patient characteristics:
• In patients with cirrhosis and low protein (<1.5 g/L),
ascites, primary SBP prophylaxis can be considered in
selected patients with renal dysfunction (serum creatinine
level >1.2 mg/dL, blood urea nitrogen level >25 mg/dL, or
serum sodium level <130 mEq/L) or liver failure (Child-
Turcotte-Pugh score >9 and bilirubin >3 mg/dL).
• It is likely most beneficial in patients who for whom liver
transplantation is imminent so add:
Norfloxacin
400mg once
daily
Ciprofloxacin 500mg once daily
Ceftriaxone 1gm IV/24hr for 7 days Trimethoprim- sulphamethoxazole
1 ds tablet/24hr
Association of SBP with PPI
Since it has been suggested that PPI may increase the
risk for the development of SBP, its use should be
restricted to those with a clear indication.
Patients on PPIs should be monitored carefully for
SBP, and if infection occurs, PPI therapy should be
reconsidered, especially if there are no clear
indications for continuing this therapy.
Norfloxacin 400mg once daily
Ciprofloxacin 500mg once daily
Trimethoprim- sulphamethoxazole 1 ds tablet/24hr
References EASL 2018
AASLD 2021
Empirical SBP/SBE management
Community acquired infections
Third generation cephalosporins
Hospital acquired infections or
Recent hospitalization in the last 90days with recent exposure to broad-spectrum antibiotics or
critically ill patients admitted in the intensive care unit
Cefotaxime 2gm iv/12hr Piperacillin-tazobactam 4.5 g IVq6hr
Ceftriaxone 2gm iv/24hr Imipenem- cilastatin 500 mg IVq6hr
Meropenem 1 g IVq8hr
if MRSA risk add one of the following:

45 | P a g e
Pyogenic hepatic abscess
Definition • Liver abscesses are the most common type of visceral abscess (an abscess within an intra-abdominal organ).
• Pyogenic liver abscesses accounted for 48 percent of visceral abscesses and 13 percent of intra-abdominal abscesses overall.
• Risk factors include diabetes mellitus, underlying hepatobiliary or pancreatic disease, liver transplant, and regular use of PPIs.
• Pyogenic liver abscess often presents with fever, right upper quadrant pain and tenderness, and elevated liver enzymes. Other potential
diagnoses with similar signs and symptoms include acute hepatitis of any cause (e.g., viral, drug induced, alcoholic), primary or secondary liver
tumors, right lower lobe pneumonia, acute cholangitis, and acute cholecystitis.
• Classified by presumed etiology:
o Bacterial: Up to 50% develop from the biliary tract. The remainder is from the hepatic artery (bacteremia), portal vein (abdominal source,
e.g., diverticulitis), contiguous focus (local abscess or cholecystitis) or penetrating trauma. Many are of cryptogenic origin.
o Parasitic: Entamoeba histolytica: abscess occurs via the portal system during amebic colitis.
Causative
Pathogens
• Gram-positive cocci: Streptococcus species (especially S. intermedius group), enterococci, and Staphylococcus aureus.
• Anaerobes: Bacteroides species, Fusobacterium sp, Actinomyces sp, Clostridium sp, etc.
• Enterobacteriaceae (E. coli, Klebsiella spp., etc.) and other Gram-negative bacilli
• Entamoeba histolytica: amebic liver abscesses may complicate up to 10% of the cases of amebic colitis
• The clinical course and imaging appearance may be difficult to distinguish from pyogenic liver abscess. Amebic abscess is best distinguished
from pyogenic liver abscess by E. histolytica serology.
Antibiotic
therapy
notes
• Astable patient, antibiotics may be deferred until post-aspiration/drainage to increase culture yield.
• Empiric broad-spectrum parenteral antibiotics should be administered pending aspiration of the abscess and microbiologic analysis of the
abscess contents. The empiric regimen should cover streptococci, enteric gram-negative bacilli, and anaerobes.
• The empiric regimen should also cover E. histolytica until the causative pathogen(s) is found or amebic abscess is excluded.
Antibiotics
duration
• Regardless of whether a causative organism has been identified, antibiotic therapy for four to six weeks total is usually recommended [63].
Patients who have had a good response to initial drainage should be treated with two to four weeks of parenteral therapy,
• While patients with incomplete drainage should receive four to six weeks of parenteral therapy.
• The remainder of the course can then be completed with oral therapy tailored to culture and susceptibility results.
• If culture results are not available, reasonable empiric oral antibiotic choices below.
Oral step-
down
therapy
Levofloxacin 750mg po once daily + metronidazole 500mg three times daily
Ciprofloxacin 500 mg po twice daily + metronidazole 500mg three times daily
amoxicillin-clavulanate 875/125 mg two to three times daily (use with caution in high-risk patients with MDR-GNR risk factors)

46 | P a g e
* We do not continue a gentamicin-containing regimen for pyogenic liver abscess beyond 48 to 72 hours. If microbiologic data are unrevealing
and a gentamicin-containing regimen was used for empiric therapy, we switch to one of these other empiric regimens to complete the antibiotic
course
**Ertapenem lacks activity against Acinetobacter and Pseudomonas and, of the carbapenems, is not an appropriate choice for severe or
nosocomial infection.
References John Hopkins guide for antibiotics
UpToDate
Primary regimens Alternatives
Fluroquinolones Carbapenems
Better reserved if drug allergy or resistance
Piperacillin-tazobactam 3.375 or 4.5 g IV q6hr Ciprofloxacin 400 mg IVq12hr Meropenem 1 g IVq8hr
Ceftriaxone 2gm IVq24hr Levofloxacin 750 mg IV once daily Imipenem- cilastatin 500 mg IVq6hr
Cefotaxime 2gm IVq8hr Ertapenem 1g IV once daily**
OR*
Ampicillin 2gm IV q6hr
PLUS
Gentamicin 1.7mg/kg IV q8hr
PLUS, Metronidazole 500 mg IVq8hr if Amebic hepatic abscess possibility

47 | P a g e
Initial Intravenous Pediatric Dosages of Antibiotics for Treatment of Complicated Intra-abdominal Infections
*Antibiotic serum concentrations and renal function should be monitored
Amoxicillin-clavulanate max. daily dose <45mg amoxicillin/kg/day
Aztreonam 90–120 mg/kg/day Every 6–8 h
Cefepime 100 mg/kg/day Every 12 h
Cefotaxime 150–200 mg/kg/day Every 6–8 h
Cefoxitin 160 mg/kg/day Every 4–6 h
Ceftazidime 150 mg/kg/day Every 8 h
Ceftriaxone 50–75 mg/kg/day Every 12–24 h
Ciprofloxacin 20-30 mg/kg/day Every 12 h
Ertapenem
3 months to 12 years 15 mg/kg twice daily (not to exceed 1 g/day) Every 12 h
>13 years 1 g/day Every 24 h
Gentamicin* 3–7.5 mg/kg/day Every 2–4 h
Imipenem-cilastatin 60–100 mg/kg/day Every 6 h
Meropenem 60 mg/kg/day Every 8 h
Metronidazole 30–40 mg/kg/day Every 8 h
Piperacillin-tazobactam 200–300 mg/kg/day of piperacillin component Every 6–8 h
Linezolid
Infants and Children <12 years: Oral, IV: 10 mg/kg/dose every 8 hours, maximum dose: 600 mg/dose.
Children ≥12 years and Adolescents: Oral, IV: 600 mg every 12 hours.
Vancomycin * 40 mg/kg/day as 1 h infusion Every 6–8 h
Levofloxacin
6 months to <5 years: Oral, IV: 8 to 10 mg/kg/dose twice daily.
≥5 years: Oral, IV: 10 mg/kg/dose once daily; maximum dose: 750 mg/day.

48 | P a g e
Clostridium Difficile
Clinical
Presentations
Diarrhea, cramps +/- fever may be acute or chronic. Occasionally, constipation or ileus occurs, especially in the postoperative patient.
Tip-offs to the probability of CDI:
Typical patient risks (agent-specific AB exposure, advanced age, exposure to the healthcare environment with current or recent CDI cases)
Diarrhea: Consider testing if ≥ 3 unformed stools within 24 hours. Stools up to 15x per day are not unusual. Often associated with abdominal
cramping and pain, nausea and anorexia Fecal WBCs or positive fecal lactoferrin GI bleeding is rarely seen.
CT evidence of pancolitis with ascites and sparing of small bowel seen in severe CDI.
Endoscopy showing pseudomembranous
Distinctive foul stool odor
Labs consistent with severe CDI: Elevated WBC (Unexplained significant leukocytosis/leukemoid-type reaction, may see extreme WBC values
50-100,000+), Hypoalbuminemia, Acute kidney injury.
Risk factors Epidemiology: Colon colonization is 2-5% in healthy adults but 20-40% in hospitalized patients.
Antibiotic risk (rank order):
• High: clindamycin, third- or fourth-generation cephalosporins (e.g., ceftriaxone, cefotaxime, cefepime), carbapenems (e.g., imipenem),
fluoroquinolones (e.g., ciprofloxacin, levofloxacin, moxifloxacin)
• Medium: Amoxicillin/clavulanate, other β-lactams or β-lactam/β-lactamase inhibitor combinations (piperacillin/tazobactam).
• Low or minimal risk: Metronidazole, vancomycin (IV), aminoglycosides, nitrofurantoin, Fosfomycin, sulfonamides, tetracyclines.
Predisposing drugs: Protein pump inhibitors, histamine receptor antagonists, antacids, nonsteroidal anti-inflammatory agents.
Host factors: Age: > 65 years Chronic renal disease, diabetes, lymphoma, leukemia, solid tissue cancer, peptic ulcers, diverticular disease, GE
reflux, Female gender, Prior CDI Immunosuppression.
Complications • Ileus and toxic megacolon with potential perforation
1. No diarrhea 2. It may be mistaken for routine ileus in postoperative abdominal surgery patients.
3. Colon distended ≥ 6 cm on imaging with loss of haustral markings; thumbprinting from mucosal wall edema may be present.
4. Pneumatosis intestinalis (not specific for CDI). 5. Perforation may occur with progressive dilatation.
• Septic shock with multiorgan system failure, renal failure, and lactic acidosis is usually seen with a high WBC count.
Treatment
notes
If possible, discontinue inciting antibiotic agent(s) as soon as feasible. If need systemic antibiotic for ongoing infection (other than C. difficile):
try to use agents less likely to promote C. difficile, if possible, e.g., vancomycin, azithromycin, clarithromycin, TMP/SMX, doxycycline,
tigecycline, gentamicin (or other aminoglycosides), narrow-spectrum beta-lactams (e.g., oxacillin).
Start empiric CDI therapy as soon as possible if a delay in laboratory confirmation is anticipated OR if the patient has fulminant CDI.

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