, Volume 65, Issue 12, pp 1611–1620 | Cite as

Critical Issues in the Clinical Management of Complicated Intra-Abdominal Infections

  • Stijn Blot
  • Jan J. De Waele
Therapy in Practice


Intra-abdominal infections differ from other infections through the broad variety in causes and severity of the infection, the aetiology of which is often polymicrobial, the microbiological results that are difficult to interpret and the essential role of surgical intervention. From a clinical viewpoint, two major types of intra-abdominal infections can be distinguished: uncomplicated and complicated. In uncomplicated intra-abdominal infection, the infectious process only involves a single organ and no anatomical disruption is present. Generally, patients with such infections can be managed with surgical resection alone and no antimicrobial therapy besides perioperative prophylaxis is necessary. In complicated intra-abdominal infections, the infectious process proceeds beyond the organ that is the source of the infection, and causes either localised peritonitis, also referred to as abdominal abscess, or diffuse peritonitis, depending on the ability of the host to contain the process within a part of the abdominal cavity. In particular, complicated intra-abdominal infections are an important cause of morbidity and are more frequently associated with a poor prognosis. However, an early clinical diagnosis, followed by adequate source control to stop ongoing contamination and restore anatomical structures and physiological function, as well as prompt initiation of appropriate empirical therapy, can limit the associated mortality.

The biggest challenge with complicated intra-abdominal infections is early recognition of the problem. Antimicrobial management is generally standardised and many regimens, either with monotherapy or combination therapy, have proven their efficacy. Routine coverage against enterococci is not recommended, but can be useful in particular clinical conditions such as the presence of septic shock in patients previously receiving prolonged treatment with cephalosporins, immunosuppressed patients at risk for bacteraemia, the presence of prosthetic heart valves and recurrent intra-abdominal infection accompanied by severe sepsis. In patients with prolonged hospital stay and antibacterial therapy, the likelihood of involvement of antibacterial-resistant pathogens must be taken into account. Antimicrobial coverage of Candida spp. is recommended when there is evidence of candidal involvement or in patients with specific risk factors for invasive candidiasis such as immunodeficiency and prolonged antibacterial exposure. In general, antimicrobial therapy should be continued for 5–7 days. If sepsis is still present after 1 week, a diagnostic work up should be performed, and if necessary a surgical reintervention should be considered.


Peritonitis Antibacterial Therapy Source Control Drotrecogin Alfa Secondary Peritonitis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Jan J. De Waele is supported by a Clinical Doctoral Fund of the Fund for Scientific Research — Flanders (FWO). The authors have no conflicts of interest that are directly relevant to the content of this review.


  1. 1.
    Berger D, Buttenschoen K. Management of abdominal sepsis. Langenbecks Arch Surg 1998; 383: 35–43PubMedCrossRefGoogle Scholar
  2. 2.
    Pine RW, Wertz MJ, Lennard ES, et al. Determinants of organ malfunction or death in patients with intra-abdominal sepsis: a discriminant analysis. Arch Surg 1983; 118: 242–9PubMedCrossRefGoogle Scholar
  3. 3.
    Mulier S, Penninckx F, Verwaest C, et al. Factors affecting mortality in generalized postoperative peritonitis: multivariate analysis in 96 patients. World J Surg 2003; 27: 379–84PubMedCrossRefGoogle Scholar
  4. 4.
    Bohnen J, Boulanger M, Meakins JL, et al. Prognosis in generalized peritonitis: relation to cause and risk factors. Arch Surg 1983; 118: 285–90PubMedCrossRefGoogle Scholar
  5. 5.
    Nathens AB, Rotstein OD, Marshall JC. Tertiary peritonitis: clinical features of a complex nosocomial infection. World J Surg 1998; 22: 158–63PubMedCrossRefGoogle Scholar
  6. 6.
    Pitcher WD, Musher DM. Critical importance of early diagnosis and treatment of intra-abdominal infection. Arch Surg 1982; 117: 328–33PubMedCrossRefGoogle Scholar
  7. 7.
    Evans HL, Raymond DP, Pelletier SJ, et al. Diagnosis of intra-abdominal infection in the critically ill patient. Curr Opin Crit Care 2001; 7: 117–21PubMedCrossRefGoogle Scholar
  8. 8.
    Marshall JC, Innes M. Intensive care unit management of intra-abdominal infection. Crit Care Med 2003; 31: 2228–37PubMedCrossRefGoogle Scholar
  9. 9.
    Wittmann DH, Schein M, Condon RE. Management of secondary peritonitis. Ann Surg 1996; 224: 10–8PubMedCrossRefGoogle Scholar
  10. 10.
    Dougherty SH. Antimicrobial culture and susceptibility testing has little value for routine management of secondary bacterial peritonitis. Clin Infect Dis 1997; 25 Suppl. 2: S258–61PubMedCrossRefGoogle Scholar
  11. 11.
    Falagas ME, Barefoot L, Griffith J, et al. Risk factors leading to clinical failure in the treatment of intra-abdominal or skin/soft tissue infections. Eur J Clin Microbiol Infect Dis 1996; 15: 913–21PubMedCrossRefGoogle Scholar
  12. 12.
    Mosdell DM, Morris DM, Voltura A, et al. Antibiotic treatment for surgical peritonitis. Ann Surg 1991; 214: 543–9PubMedCrossRefGoogle Scholar
  13. 13.
    Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med 2004; 30: 536–55PubMedCrossRefGoogle Scholar
  14. 14.
    Schein M, Marshall J. Source control: a guide to the management of surgical infections. Heidelberg: Springer Verlag, 2002Google Scholar
  15. 15.
    Montgomery RS, Wilson SE. Intraabdominal abscesses: image-guided diagnosis and therapy. Clin Infect Dis 1996; 23: 28–36PubMedCrossRefGoogle Scholar
  16. 16.
    Gorecki P, Schein M, Rucinski JC, et al. Antibiotic administration in patients undergoing common surgical procedures in a community teaching hospital: the chaos continues. World J Surg 1999; 23: 429–32PubMedCrossRefGoogle Scholar
  17. 17.
    Wasey N, Baughan J, de Gara CJ. Prophylaxis in elective colorectal surgery: the cost of ignoring the evidence. Can J Surg 2003; 46: 279–84PubMedGoogle Scholar
  18. 18.
    Mazuski JE, Sawyer RG, Nathens AB, et al. The Surgical Infection Society guidelines on antimicrobial therapy for intra-abdominal infections: an executive summary. Surg Infect (Larchmt) 2002; 3: 161–73CrossRefGoogle Scholar
  19. 19.
    Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis 2003; 37: 997–1005PubMedCrossRefGoogle Scholar
  20. 20.
    Kirton OC, O’Neill PA, Kestner M, et al. Perioperative antibiotic use in high-risk penetrating hollow viscus injury: a prospective randomized, double-blind, placebo-control trial of 24 hours versus 5 days. J Trauma 2000; 49: 822–32PubMedCrossRefGoogle Scholar
  21. 21.
    Lennard ES, Dellinger EP, Wertz MJ, et al. Implications of leukocytosis and fever at conclusion of antibiotic therapy for intra-abdominal sepsis. Ann Surg 1982; 195: 19–24PubMedCrossRefGoogle Scholar
  22. 22.
    Hartstein AI, Mulligan ME, Morthland VH, et al. Recurrent Staphylococcus aureus bacteremia. J Clin Microbiol 1992; 30: 670–4PubMedGoogle Scholar
  23. 23.
    Oude Lashof AM, Donnelly JP, Meis JF, et al. Duration of antifungal treatment and development of delayed complications in patients with candidaemia. Eur J Clin Microbiol Infect Dis 2003; 22: 43–8PubMedGoogle Scholar
  24. 24.
    Vuagnat A, Stern R, Lotthe A, et al. High dose vancomycin for osteomyelitis: continuous vs intermittent infusion. J Clin Pharm Ther 2004; 29: 351–7PubMedCrossRefGoogle Scholar
  25. 25.
    Dougherty SH. Role of enterococcus in intraabdominal sepsis. Am J Surg 1984; 148: 308–12PubMedCrossRefGoogle Scholar
  26. 26.
    Harbarth S, Uckay I. Are there patients with peritonitis who require empiric therapy for enterococcus? Eur J Clin Microbiol Infect Dis 2004; 23: 73–7PubMedCrossRefGoogle Scholar
  27. 27.
    Barie PS, Christou NV, Dellinger EP, et al. Pathogenicity of the enterococcus in surgical infections. Ann Surg 1990; 212: 155–9PubMedCrossRefGoogle Scholar
  28. 28.
    Carmeli Y, Troillet N, Karchmer AW, et al. Health and economic outcomes of antibiotic resistance in Pseudomonas aeruginosa. Arch Intern Med 1999; 159: 1127–32PubMedCrossRefGoogle Scholar
  29. 29.
    Walker AP, Nichols RL, Wilson RF, et al. Efficacy of a beta-lactamase inhibitor combination for serious intraabdominal infections. Ann Surg 1993; 217: 115–21PubMedCrossRefGoogle Scholar
  30. 30.
    Cohn SM, Lipsett PA, Buchman TG, et al. Comparison of intravenous/oral ciprofloxacin plus metronidazole versus piperacillin/tazobactam in the treatment of complicated intraabdominal infections. Ann Surg 2000; 232: 254–62PubMedCrossRefGoogle Scholar
  31. 31.
    Ohlin B, Cederberg A, Forssell H, et al. Piperacillin/tazobactam compared with cefuroxime/metronidazole in the treatment of intra-abdominal infections. Eur J Surg 1999; 165: 875–84PubMedCrossRefGoogle Scholar
  32. 32.
    Harbarth S, Cosgrove S, Carmeli Y. Effects of antibiotics on nosocomial epidemiology of vancomycin-resistant enterococci. Antimicrob Agents Chemother 2002; 46: 1619–28PubMedCrossRefGoogle Scholar
  33. 33.
    Patel R, Badley AD, Larson-Keller J, et al. Relevance and risk factors of enterococcal bacteremia following liver transplantation. Transplantation 1996; 61: 1192–7PubMedCrossRefGoogle Scholar
  34. 34.
    Fernandez-Guerrero ML, Herrero L, Bellver M, et al. Nosocomial enterococcal endocarditis: a serious hazard for hospitalized patients with enterococcal bacteraemia. J Intern Med 2002; 252: 510–5PubMedCrossRefGoogle Scholar
  35. 35.
    Sawyer RG, Rosenlof LK, Adams RB, et al. Peritonitis into the 1990s: changing pathogens and changing strategies in the critically ill. Am Surg 1992; 58: 82–7PubMedGoogle Scholar
  36. 36.
    Rotstein OD, Pruett TL, Simmons RL. Microbiologic features and treatment of persistent peritonitis in patients in the intensive care unit. Can J Surg 1986; 29: 247–50PubMedGoogle Scholar
  37. 37.
    Sotto A, Lefrant JY, Fabbro-Peray P, et al. Evaluation of antimicrobial therapy management of 120 consecutive patients with secondary peritonitis. J Antimicrob Chemother 2002; 50: 569–76PubMedCrossRefGoogle Scholar
  38. 38.
    Aloia T, Solomkin J, Fink AS, et al. Candida in pancreatic infection: a clinical experience. Am Surg 1994; 60: 793–6PubMedGoogle Scholar
  39. 39.
    De Waele JJ, Vogelaers D, Blot S, et al. Fungal infections in patients with severe acute pancreatitis and the use of prophylactic therapy. Clin Infect Dis 2003; 37: 208–13PubMedCrossRefGoogle Scholar
  40. 40.
    Eggimann P, Francioli P, Bille J, et al. Fluconazole prophylaxis prevents intra-abdominal candidiasis in high-risk surgical patients. Crit Care Med 1999; 27: 1066–72PubMedCrossRefGoogle Scholar
  41. 41.
    Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004; 38: 161–89PubMedCrossRefGoogle Scholar
  42. 42.
    Holzheimer RG, Dralle H. Management of mycoses in surgical patients: review of the literature. Eur J Med Res 2002; 7: 200–26PubMedGoogle Scholar
  43. 43.
    Blot S, Vandewoude K. Management of invasive candidiasis in critically ill patients. Drugs 2004; 64: 2159–75PubMedCrossRefGoogle Scholar
  44. 44.
    File Jr TM. Overview of resistance in the 1990s. Chest 1999; 115: 3S-8SCrossRefGoogle Scholar
  45. 45.
    Schaberg DR, Culver DH, Gaynes RP. Major trends in the microbial etiology of nosocomial infection. Am J Med 1991; 91: 72S-5SCrossRefGoogle Scholar
  46. 46.
    Garbino J, Kolarova L, Rohner P, et al. Secular trends of candidemia over 12 years in adult patients at a tertiary care hospital. Medicine (Baltimore) 2002; 81: 425–33CrossRefGoogle Scholar
  47. 47.
    Blot S, Vandewoude K, De Bacquer D, et al. Nosocomial bacteremia caused by antibiotic-resistant gram-negative bacteria in critically ill patients: clinical outcome and length of hospitalization. Clin Infect Dis 2002; 34: 1600–6PubMedCrossRefGoogle Scholar
  48. 48.
    Blot SI, Vandewoude KH, Hoste EA, et al. Outcome and attributable mortality in critically ill patients with bacteremia involving methicillin-susceptible and methicillin-resistant Staphylococcus aureus. Arch Intern Med 2002; 162: 2229–35PubMedCrossRefGoogle Scholar
  49. 49.
    Lodise TP, McKinnon PS, Tam VH, et al. Clinical outcomes for patients with bacteremia caused by vancomycin-resistant enterococcus in a level 1 trauma center. Clin Infect Dis 2002; 34: 922–9PubMedCrossRefGoogle Scholar
  50. 50.
    Cosgrove SE, Carmeli Y. The impact of antimicrobial resistance on health and economic outcomes. Clin Infect Dis 2003; 36: 1433–7PubMedCrossRefGoogle Scholar
  51. 51.
    Kollef MH. Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients. Clin Infect Dis 2000; 31 Suppl. 4: S131–8PubMedCrossRefGoogle Scholar
  52. 52.
    Kollef M. Appropriate empirical antibacterial therapy for nosocomial infections: getting it right the first time. Drugs 2003; 63: 2157–68PubMedCrossRefGoogle Scholar
  53. 53.
    De Waele JJ, Vogelaers D, Hoste E, et al. Emergence of antibiotic resistance in infected pancreatic necrosis. Arch Surg 2004; 139: 1371–5PubMedCrossRefGoogle Scholar
  54. 54.
    Blot S, Vandewoude K. Early detection of systemic infection. Acta Clin Belg 2004; 59: 20–3PubMedGoogle Scholar
  55. 55.
    Blot S, Depuydt P, Vogelaers D, et al. Colonization status and appropriate antibiotic therapy in nosocomial bacteremia caused by antibiotic-resistant gram-negative bacteria in an ICU. Infect Control Hosp Epidemiol 2005; 26: 575–9PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2005

Authors and Affiliations

  1. 1.Intensive Care DepartmentGhent University HospitalGhentBelgium
  2. 2.Healthcare DepartmentHogeschool Gent, “Vesalius”GhentBelgium

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