Management of Intra-abdominal Infection

Publication Date: July 11, 2024
Last Updated: July 17, 2024

Aminoglycosides

We recommend against aminoglycoside-based combination regimens for empiric therapy of higher risk patients. ( 1 , A )
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Beta-lactamase inhibitor combinations

We recommend cefoperazone-sulbactam for empiric therapy of lower risk patients. ( 1 , B )
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We recommend imipenem-cilastatin-relebactam for empiric therapy. ( 1 , A )
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We suggest reserving imipenem-cilastatin-relebactam for higher risk patients due to its broader spectrum antimicrobial agent activity. ( 2 , C )
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We recommend ceftolozane-tazobactam plus metronidazole for empiric therapy. ( 1 , A )
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We suggest reserving ceftolozane-tazobactam for higher risk patients, including those with resistant Pseudomonas aeruginosa infections. ( 2 , C )
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We suggest ceftolozane-tazobactam for empiric therapy of patients at risk for infection with extended-spectrum β-lactamase (ESBL)-producing Enterobacterales. ( 2 , B )
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We recommend ceftazidime-avibactam plus metronidazole for empiric therapy. ( 1 , A )
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We suggest reserving ceftazidime-avibactam for higher risk patients because of its broader spectrum antimicrobial agent activity. ( 2 , C )
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We recommend ceftazidime-avibactam plus metronidazole for empiric therapy of patients at risk for infection with ESBL-producing Enterobacterales. ( 1 , B )
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Glycylcyclines

We recommend eravacycline for empiric therapy. ( 1 , A )
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We suggest reserving eravacycline for higher risk patients due to its broader spectrum antimicrobial agent activity. ( 2 , C )
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We recommend against tigecycline for empiric therapy of low- and high-risk patients. ( 1 , B )
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We suggest reserving tigecycline for patients with resistant infections or as part of a combination regimen when no therapeutic alternative exists. ( 2 , B )
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Carbapenems

We suggest biapenem for empiric therapy. ( 2 , B )
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We suggest reserving biapenem for higher risk patients because of its broader spectrum antimicrobial agent activity. ( 2 , C )
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We recommend doripenem for empiric therapy. ( 1 , A )
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We suggest reserving doripenem for higher risk patients because of its broader spectrum antimicrobial agent activity. ( 2 , C )
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Fluoroquinolones

We recommend ciprofloxacin plus metronidazole for empiric therapy of lower risk patients. ( 1 , A )
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We suggest moxifloxacin for empiric therapy of lower risk patients. ( 2 , A )
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Glycopeptides

We recommend against vancomycin for empiric therapy of low- and high-risk patients. ( 1 , B )
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Metronidazole

We recommend metronidazole as the preferred anti-anaerobic agent in combination regimens for empiric therapy of low- and high-risk patients. ( 1 , A )
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Polymyxins

We suggest polymyxin B for empiric therapy of higher risk patients with MDR infection, including P. aeruginosa, Acinetobacter baumannii complex, Klebsiella pneumoniae, Escherichia coli, and Enterobacter spp. ( 2 , B )
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Anti-fungal therapy

We suggest against empiric anti-fungal therapy in lower risk patients. ( 2 , B )
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Anidulafungin

We recommend anidulafungin for empiric therapy of higher risk patients with infections from Candida spp. ( 1 , B )
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Anti-enterococcal therapy

We recommend against empiric therapy targeting Enterococcus spp. in lower risk patients with CA-IAI. ( 1 , B )
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We suggest empiric therapy targeting Enterococcus spp. in higher risk patients. ( 2 , B )
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Hepatopancreatobiliary malignant disease

We recommend targeted, perioperative antibiotic agent prophylaxis based on a positive preoperative bile culture in patients undergoing surgical procedures for hepatopancreatobiliary malignant disease. ( 1 , A )
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We suggest antibiotic agent prophylaxis for at least 24 hours in patients undergoing pancreatoduodenectomy with positive bile cultures following preoperative biliary drainage to prevent organ-space SSI. ( 2 , C )
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Appendicitis

We recommend oral moxifloxacin for empiric therapy of lower risk patients undergoing non-operative management of acute uncomplicated appendicitis. ( 1 , B )
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We recommend substitution of oral for IV antibiotic agents to complete a short course (24 h) of therapy in lower risk patients with acute complicated appendicitis undergoing adequate source control by laparoscopic appendectomy. ( 1 , B )
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We suggest a carbapenem for empiric therapy of patients undergoing non-operative management of acute appendicitis. ( 2 , B )
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We suggest limiting post-operative antibiotic agents to 24-48 hours for low- and high-risk patients with adequate source control for complicated appendicitis undergoing appendectomy. ( 2 , B )
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We suggest against antibiotic agent prophylaxis in lower risk patients undergoing elective laparoscopic appendectomy for chronic appendicitis. ( 2 , B )
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Abdominal trauma

We suggest ertapenem for antibiotic agent prophylaxis in low- and high-risk patients undergoing laparotomy for traumatic injury. ( 2 , B )
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Duration of antibiotic agent therapy

We recommend limiting antimicrobial agent therapy to four days for low- and high-risk patients with source control achieved via a percutaneous drainage procedure. ( 1 , B )
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We recommend limiting antimicrobial agent therapy to four days after achieving source control in high-risk patients with sepsis. ( 1 , B )
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We recommend limiting antimicrobial agent therapy to four days after achieving source control in higher risk patients at increased risk of complications from diabetes mellitus, obesity, or higher illness severity. ( 1 , B )
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We suggest limiting antimicrobial agent therapy to eight days in critically ill patients after achieving adequate source control of IAI. ( 2 , B )
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De-escalation of antibiotic agent therapy

We suggest de-escalation of antibiotic agent therapy in ICU patients with HA-IAI. ( 2 , B )
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We suggest maintaining anaerobic coverage with de-escalation of antibiotic agent therapy. ( 2 , C )
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Timing of source control procedures

We recommend undertaking source control within 12 hours in lower risk patients. ( 1 , B )
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We recommend undertaking source control within six hours in higher risk patients with associated septic shock. ( 1 , B )
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Antimicrobial agent stewardship

We recommend implementation of empiric antimicrobial agent therapy protocols to improve antimicrobial agent stewardship. ( 1 , B )
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Management of Intra-abdominal Infection

Authoring Organization

Surgical Infection Society

Publication Month/Year

July 11, 2024

Last Updated Month/Year

July 22, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The Surgical Infection Society (SIS) published evidence-based guidelines for the management of intra-abdominal infection (IAI) in 1992, 2002, 2010, and 2017. Here, we present the most recent guideline update based on a systematic review of current literature. Methods: The writing group, including current and former members of the SIS Therapeutics and Guidelines Committee and other individuals with content or guideline expertise within the SIS, working with a professional librarian, performed a systematic review using PubMed/Medline, the Cochrane Library, Embase, and Web of Science from 2016 until February 2024. Keyword descriptors combined "surgical site infections" or "intra-abdominal infections" in adults limited to randomized controlled trials, systematic reviews, and meta-analyses. Additional relevant publications not in the initial search but identified during literature review were included. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was utilized to evaluate the evidence. The strength of each recommendation was rated strong (1) or weak (2). The quality of the evidence was rated high (A), moderate (B), or weak (C). The guideline contains new recommendations and updates to recommendations from previous IAI guideline versions. Final recommendations were developed by an iterative process. All writing group members voted to accept or reject each recommendation. Results: This updated evidence-based guideline contains recommendations from the SIS for the treatment of adult patients with IAI. Evidence-based recommendations were developed for antimicrobial agent selection, timing, route of administration, duration, and de-escalation; timing of source control; treatment of specific pathogens; treatment of specific intra-abdominal disease processes; and implementation of hospital-based antimicrobial agent stewardship programs. Summary: This document contains the most up-to-date recommendations from the SIS on the prevention and management of IAI in adult patients.

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory, Childcare center, Emergency care, Hospital, Operating and recovery room

Intended Users

Epidemiology infection prevention, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D059413 - Intraabdominal Infections

Keywords

cephalosporin, intra-abdominal infection, Penicillin–β-lactamase inhibitor combinations, Aminoglycoside-based regimens

Source Citation

Huston JM, Barie PS, Dellinger EP, Forrester JD, Duane TM, Tessier JM, Sawyer RG, Cainzos MA, Rasa K, Chipman JG, Kao LS, Pieracci FM, Colling KP, Heffernan DS, Lester J; Therapeutics and Guidelines Committee. The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update. Surg Infect (Larchmt). 2024 Jul 11. doi: 10.1089/sur.2024.137. Epub ahead of print. PMID: 38990709.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
589
Literature Search Start Date
January 1, 2016
Literature Search End Date
February 1, 2024