PH IAI Guidelines 12.01.16 - FormWeb

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Palmetto Health Guidelines for Management of Intraabdominal Infections (IAI) in Hospitalized Adults

Empirical Antimicrobial Therapy

Suspected or Confirmed

Intraabdominal Infection (IAI)

Community--Onset

Ceftriaxone 2 G IV Q24h + Metronidazole 500 mg IV/PO Q8h

Hospital--Acquired, Re--opening Abdominal Surgery,

Severely Immunocompromised, or Critically Ill*

Piperacillin--tazobactam 3.375?4.5 G IV Q6h#

OR

Cefepime 2 G IV Q8 h ?Q12h + Metronidazole 500 mg IV Q8h

Obtain 2 sets of blood cultures in all hospitalized adults with IAI prior to starting antibiotics. Also obtain fluid or tissue cultures from the primary

site of infection, as applicable.

Daily assessment of antimicrobial regimen is strongly encouraged: 1) Revision of empirical antimicrobial therapy based on identification of microorganism, 2) Further streamlining to definitive therapy based on antimicrobial susceptibility testing results

All dosages provided assume normal renal and hepatic function.

Duration of therapy is 4 to 7 days after source control in localized IAI.1--3 Consider a 2--week course in patients with bloodstream infections.4 Please refer to PH Guidelines for Management of Gram--Negative Bloodstream Infections in Adults for further guidance.

The non--stratified use of fluoroquinolones for empirical therapy of hospitalized adults with IAI is not recommended due to increasing rates of antimicrobial resistance among E. coli and other gram--negative isolates.5 (see Fluoroquinolone Resistance Score)

* Critically ill and previous MRSA infections: Consider adding vancomycin# 15 mg/kg IV Q8h?Q12h (consider pharmacy consult for dosing)

# If adding vancomycin, consider using cefepime + metronidazole regimen. Concomitant use of vancomycin and piperacillin/tazobactam is associated with an increased risk of nephrotoxicity.6--8

PH Pharmacy & Therapeutics Committee Approval:

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Definitions:

? Hospital--acquired infection: symptom onset >5 days after hospital admission. ? Critically ill: persistent hypotension, unexplained metabolic acidosis, ICU admission, qSOFA score 2, or Pitt bacteremia score 4.9

? Severely immunocompromised host: Chemotherapy, neutropenia, transplant recipient, treatment with high dose steroids (>20 mg of prednisone equivalents daily for >2 weeks) or other immunosuppressive medications within one month.

Source Control:

? Optimal management of IAI includes appropriate antimicrobial therapy as well as adequate source control (relief of biliary obstruction, drainage of intra--abdominal or pelvic abscesses, etc.).

Alternate Antimicrobial Regimens:

--lactam Allergy

? Patients with penicillin allergy should not receive piperacillin--tazobactam. ? In patients with minor penicillin allergies (nonspecific rashes, intolerance, etc.), cross reactivity with 2nd, 3rd and 4th generation

cephalosporins is low (< 3%).10 The benefit from beta--lactam antibiotics outweighs the potential risk in these patients.11

? In patients with serious reactions to --lactams (anaphylaxis, angioedema, breathing problems and hives), levofloxacin 750 mg PO/IV Q24h + metronidazole 500 mg PO/IV Q8h is preferred in the absence of nursing home residence or prior exposure to a fluoroquinolone in the past six months (i.e. Fluoroquinolone Resistance Score 4 mg/dL) precluding ceftriaxone use or metronidazole intolerance

? Cefoxitin 2g IV Q8h may be used in mild IAI in the absence of prior exposure to --lactam antibiotics within the past one month.1,13

Risk Factors for Antimicrobial Resistance:

? Extended--spectrum beta--lactamase (ESBL)--producing Enterobacteriaceae

o A carbapenem is preferred in patients with high risk of IAI due to ESBLs (i.e. ESBL Prediction Score 3). Risk factors include: ? 2 courses of --lactam or fluoroquinolone antibiotics within the past 3 months. ? Documentation of prior infections or colonization with ESBL--producing organisms in the past 12 months.14

? Carbapenem--resistant Enterobacteriaceae (CRE)

o Risk factors include: ? Documentation of prior infections or colonization with CRE in the past 12 months. ? Receipt of 7 days of carbapenems in the past 3 months.15

Contact the Antimicrobial Stewardship and Support Team (ASST) during business hours or an Infectious Diseases specialist for assistance in determining optimal empirical/definitive antimicrobial therapy.

PH Pharmacy & Therapeutics Comm ittee Approval:

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References:

1. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra--abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010; 50: 133--64.

2. Gomi H, Solomkin JS, Takada T, et al; Tokyo Guideline Revision Committee. TG13 antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:60--70.

3. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short--course antimicrobial therapy for intraabdominal infection. N Engl J Med 2015; 372:1996--2005.

4. Nelson A, Justo JA, Bookstaver PB, Kohn J, Albrecht H, Al--Hasan MN. Optimal duration of antimicrobial therapy for bloodstream infections due to gram--negative bacilli. IDWeek, New Orleans, LA, 26--30 October 2016. Abstract #59811.

5. Al--Hasan MN, Lahr BD, Eckel--Passow JE, Baddour LM. Antimicrobial resistance trends of Escherichia coli bloodstream isolates: a population-- based study, 1998--2007. J Antimicrob Chemother 2009;64:169--74.

6. Justo JA, Dickert EL, Kohn J, Bookstaver PB. Comparative risk of acute kidney injury in patients receiving vancomycin monotherapy or vancomycin and beta--lactam combination therapy. 54th Interscience Conference on Antimicrobial Agents and Chemotherapy, Washington DC, 5--9 September 2014. Abstract #2544.

7. Gomes DM, Smotherman C, Birch A, et al. Comparison of acute kidney injury during treatment with vancomycin in combination with piperacillin--tazobactam or cefepime. Pharmacotherapy 2014;34:662--9.

8. Burgess LD, Drew RH. Comparison of the incidence of vancomycin--induced nephrotoxicity in hospitalized patients with and without concomitant piperacillin--tazobactam. Pharmacotherapy 2014;34:670--6.

9. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis--3). JAMA 2016; 315:801--10.

10. Pichichero ME. Cephalosporins can be prescribed safely for penicillin--allergic patients. J Fam Pract 2006;55:106--12. 11. Jeffres MN, Narayanan PP, Shuster JE, Schramm GE. Consequences of avoiding --lactams in patients with --lactam allergies. J Allergy Clin

Immunol 2016;137:1148--53.

12. Dan S, Shah A, Justo JA, et al. Prediction of fluoroquinolone resistance in gram--negative bacteria causing bloodstream infections. Antimicrob

Agents Chemother 2016; 60:2265--72. 13. Hammer KL, Stoessel A, Justo JA, et al. Association between chronic hemodialysis and bloodstream infections due to chromosomally--

mediated AmpC--producing Enterobacteriaceae. Am J Infect Control 2016. doi: 10.1016/j.ajic.2016.05.017. [Epub ahead of print] 14. Augustine MR, Testerman TL, Justo JA, et al. Clinical risk score for prediction of extended--spectrum beta--lactamase--producing

Enterobacteriaceae in bloodstream isolates. ASM Microbe 2016, Boston, MA, 16--20 June 2016. Abstract #1590. 15. Orsi GB, Bencardino A, Vena A, et al. Patient risk factors for outer membrane permeability and KPC--producing carbapenem--resistant

Klebsiella pneumoniae isolation: results of a double case--control study. Infection 2013;41:61--7.

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