Tag: empirical antimicrobial therapy

Canadian practice guidelines for surgical intra-abdominal infections

by mediconepal

October 17, 2016

EXECUTIVE SUMMARY Complicated intra-abdominal infections (IAIs) remain a major challenge in clinical practice. In addition to significant morbidity and mortality ...

EXECUTIVE SUMMARY Complicated intra-abdominal infections (IAIs) remain a major challenge in clinical practice. In addition to significant morbidity and mortality for patients, they consume substantial hospital resources. This is compounded by the potential misuse of antimicrobial agents that may result in suboptimal treatment, as well as encourage the selection and spread of antibiotic-resistant microorganisms in the health care setting. The present guideline was developed jointly by the Canadian Surgical Society (CSS) and the Association of Medical Microbiology and Infectious Disease (AMMI) Canada. The primary goal was to provide updated recommendations for the medical and surgical management of complicated IAIs since publication of the 2003 antimicrobial treatment guideline by the Infectious Diseases Society of America (IDSA) (1). Particular focus is directed at risk stratification for poor outcome based on epidemiological studies, current status of antimicrobial susceptibility and resistance profiles among enteric pathogens, therapeutic efficacy of antimicrobial regimens based on randomized clinical trials, operative versus percutaneous approaches for source control, the role of intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in IAI, and infection control and preventive measures for postoperative IAIs and surgical site infections. An additional objective is to categorize the recommendations according to the strength and quality of the available evidence using a standardized grading system. Importantly, the current guideline provides recommendations for initial empirical antimicrobial management of complicated IAIs based on clinical settings and issues unique to the Canadian health care system. Summarized below are the key evidence-based recommendations grouped according to the main sections discussed in more detail in the guideline. Each recommendation is rated by the strength of support (category A to C) and quality of evidence (grade 1 to 3) as assessed by the working group of the guideline. Key recommendations for risk assessment and stratification Recommendation 1. Categorize the severity of illness by using the Acute Physiology and Chronic Health Evaluation II (APACHE II) score: low-moderate (lower than 15) or high (15 or greater) (A-2 evidence). Although the APACHE II scoring is infrequently used clinically outside of the critical care setting at present, it is recommended that physicians and surgeons consider introducing it into clinical use in patients with IAIs. A user-friendly APACHE II calculator can be found on the following Web site . Recommendation 2. Identify high-risk patients for poor outcome by stratification according to community-acquired versus health care-associated IAIs, previous antibiotic exposure, and underlying comorbid conditions such as diabetes, severe cardiopulmonary disease or immunosuppression (A-2 evidence) Recommendation 3. Use the severity of illness score (APACHE II) and other risk factors outlined above to plan appropriate medical or surgical therapy, and for evaluating the efficacy of different antimicrobial regimens for complicated IAIs (A-2 evidence) Key recommendations for microbiology and antimicrobial susceptibility testing Recommendation 4. Due to the predominance of certain virulent pathogens in IAIs, the concept of ‘core’ pathogens is recommended for planning initial empirical antimicrobial therapy (A-2 evidence). Recommendation 5. The microbiology of community-acquired IAIs in the absence of previous antimicrobial exposure generally consists of ‘core’ pathogens that are readily predictable (A-2 evidence). In such patients and particularly those with mild to moderate severity of illness, routine bacteriological cultures of abdominal fluid or pus and antibiotic susceptibility testing of intra-abdominal isolates are optional and not routinely required to guide empirical antimicrobial therapy. However, such cultures may be useful for ongoing surveillance studies and generating local epidemiological data regarding antimicrobial susceptibility profiles and emerging resistance (A-2 evidence). Recommendation 6. Patients with health care-associated IAIs who have prolonged previous hospitalization (five days or more), are severely ill (APACHE II score of 15 or greater) or have received previous antimicrobial therapy (more than two days) are at a greater risk for antimicrobial-resistant pathogens source Chow et al Can J Infect Dis Med Microbiol Vol 21 No 1 Spring 2010 11 1Division of Infectious Disease, Department of Medicine, University of British Columbia and Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia; 2Division of Infectious Diseases, Department of Medicine, Queen’s University, Kingston; 3Department of Surgery, University of Toronto, Toronto, Ontario; 4Department of Surgery, University of Calgary, Calgary, Alberta; 5Departments of Pathology and Laboratory Medicine, University of Minnesota and Hennepin County Medical Center, Minnesota, USA; 6Department of Medical Microbiology and Medicine, University of Manitoba, Winnipeg, Manitoba; 7Department of Infectious Diseases and Microbiology, Hôspital Maisonneuve-Rosemont, University of Montreal, Montreal, Quebec Endorsed by the Association of Medical Microbiology and Infectious Disease (AMMI) Canada and the Canadian Association of General Surgeons (CAGS) Committee on Acute Care Surgery and Critical Care Correspondence: Dr Anthony W Chow, Division of Infectious Disease, Department of Medicine, University of British Columbia, 769 Burley Place, West Vancouver, British Columbia V7T 2A2. Telephone 604 926-4770, fax 604 926-4770, e-mail tonychow@interchange.ubc.ca

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