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Intraabdominal Infections

Intraabdominal Infections. Resat Ozaras, MD, Prof. Infection Dept. rozaras@yahoo.com. Peritonitis Inraabdominal abscess Liver and biliary system inf. Pancreas infections Splenic inf. Appendicitis and diverticulitis. Approach.

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Intraabdominal Infections

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  1. Intraabdominal Infections Resat Ozaras, MD, Prof. Infection Dept. rozaras@yahoo.com

  2. Peritonitis Inraabdominal abscess Liver and biliary system inf. Pancreas infections Splenic inf. Appendicitis and diverticulitis

  3. Approach • Abd. pain, fever, tenderness, leukocytosis intraabdominal inf.? • History and PE • Surgery consultation • Emprical Tx • Culture (blood, peritoneal fluidı...) + other studies

  4. Peritonitis • Primary peritonitis • Secondary peritonitis • Tertiary peritonitis

  5. Primaryperitonitis 1. Spontaneous peritonitis in children (<1-2%) postnecrotic cirrhosis, nephrotic syndrome 2. Spontaneous peritonitis in adults (10-30% of hospitalised cirrhotics) alcoholic cirrhosis, postnecrotic cirrhosis, viral hepatitis, heart failure, metastasis, autoimmune… 3. Tuberculous peritonititis

  6. Microbiology 70% enteric pathogens • Escherichia coli • Klebsiella pneumoniae • Streptococcus pneumoniae • Enterococci • Staphylococcus aureus (rare) • Anaerops For anaerobs, 75% bacteremia

  7. Hematogenous Lymphatic transmural migration through GI tract Vaginal Through Fallopian tubes Pathogenesis

  8. S&S • Acute fever • Abd. pain • Nausea, vomiting • Tenderness, rebound • Hypoactive bowel sounds

  9. In patients with ascites, peritoneal irritation findings may not be seen • Fever >37.8˚C

  10. TB peritonitis • Fever • Weight loss • Fatigue • Night sweats • Abdominal distension • Multiple nodules on peritoneum and omentum (in laparoscopy)

  11. Laboratuvar • In ascitis fluid Cell count (>250 PMN/mm3, > 500 leukocyte/mm3) Protein (serum-ascites albumin gradient <1,1) LDH (ascites/serum >0,4) Gram Staining (60-80% negative) Culture (40% negative)

  12. CT: to exclude any primary focus of intaabdominal inf. • Response to emprical antibiotics within 48-72 h.

  13. Tx • Emprical ampicillin+aminoglycoside 3rd gen. Ceph. piperacilin piperacilin-tazobactam, ampicillin- sulbactam carbapenems levofloxacine, moxifloxacin

  14. Secondary peritonitis • The integrity of GI tract is broken • Etiology depend upon the damaged site • Polymicrobial • E.coli (early mortality) • B. fragilis (late abscess development)

  15. Secondary peritonitis • Gastrointestinal perforation (appendicitis, gastroduodenal ulcer perforation, cancer perforation, bile duct perforation…) • Intestinal ischemia-perforation (mesenteric occlusion, strangulation of hernia) • Postoperative peritonitis (anastomosis leak, blind loop leak, iatrogenic peroperative damages)

  16. 4. Posttraumatic peritonitis (penetrating, blunt trauma) 5. Pelvic peritonitis (septic abortus, puerperal sepsis, salpyngitis, purulant prostatitis)

  17. Aerops Escherichiacoli %65 Proteusspp. %25 Klebsiellaspp. %20 Pseudomonasspp. %15 Enterococcir %15 Streptococcir %10 Anaerops Bacteroidesfragilis %80 Bacteroidesspp. %30 Clostridiumspp. %65 Peptostreptococcusspp. %25 Peptococcusspp. %15 Fusobacteriumspp. %20 Microbiology

  18. Clinical • Abd. pain (severe on the inflamed site, increases on movement), anorexia, nausea, vomiting, dehydration due to hypovolemia, chills, fever. • Hypotention, tachycardia, oliguria, tachypnea (due to hypovolemia, hypoxia, and acidosis • Adynamic ileus

  19. Tenderness, guarding, rebound: helpful for localising the site and the diagnosis. • Bowel sounds: initially hyperactive then silence….

  20. Dx • Leukocytosis, left-shift (stabs) • Hemoconcentration and dehydration: high hematocrit and BUN • High ALT/AST, low platelets, acidosis, high D-dimer • Plain abdominal X-ray, chest X-ray • Abdominal US, CT • Surgical or CT-guided sample: gram and culture, BC (20-30% bacteremia)

  21. Prognosis • Age • Co-morbidity • Peritoneal contamination time • “Foreign” substance (biliary and pancreatic secretions) • Microorganism • Mortality: 3.5-60%

  22. Tx • Surgery + supportive+ antibiotics (leukocytes, fever, bowel sounds…) • 5- 7 days after an appropriate surgical control

  23. Ampirik antibiyoterapi • Community-acq. mild-moderatecefazolin+metronidazol severe piperacillin-tazobactam ceftriaxon+metronidazol clindamicin+gentamicin imipenem • Hospitalacq. piperacillin+metronidazol +aminoglycoside imipenem+/-aminoglycoside Enterokococci , Candida ??

  24. Treatment Guidelines for Intra-abdominal Infections • CID 2003:37 (15 October)

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