THE ROLE OF

ANTIBIOTIC IN
ABDOMINAL SEPSIS
IBRAHIM AHMADSYAH
SCHOOL OF MEDICINE
UNIVERSITY OF INDONESIA
INTRA ABDOMINAL INFECTION

PERITONITIS
- PRIMARY
- SECONDARY
- TERTIARY
ABSCESS FORMATION
ORGAN /SPACE SURGICAL SITE
INFECTION (SSI)
PRIMARY PERITONITIS

Extra abdominal source of

hematogenously transmitted bacterial
infection
Spontaneous bacterial peritonitis(SBP),
tbc peritonitis, peritonitis associated
with CAPD
Group A Streptococcus, S.aureus and
Steptococcus pneumoniae are the most
common organisms
TERTIARY PERITONITIS

Prolonged use of antibiotics

Opportunistic infection with
normally non pathogenic gut flora
The development of tertiary
peritonitis is a serious occurrence
and a poor prognosis
SURGICAL SITE INFECTION
(CDC NNIS definitions)

Organ/Space SSI

Infections occurs within 30 days after the

operation if no implant is left in place or within
1 year if implant is in place and the infection
appears to be related to the operation and
infection involves any part of the anatomy,
other than the incision, which was opened or
manipulated during an operation
SURGICAL SITE INFECTION
(SSI)

Gram positive infection in

surgery on the soft tissues
Aerobic gram negative
or anaerobic pathogen in
surgery of the visceral
organs
 SURGICAL SITE INFECTION
(SSI)

Remain a substantial cause of morbidity &

mortality among hospitalized patients, due to :

Emergence of antimicrobial resistant pathogen

Increased number of surgical patients who are
elderly and/or have a wide variety of chronic
or immuno-compromising underlying disease
Increased number of prostetic implant and
organ transplant operations
MANAGEMENT OF ABDOMINAL
INFECTION
THREE OBJECTIVES:

The elimination of the source of

infection
The elimination of toxic material by
adequate surgical cleaning and
antimicrobial therapy
The control of systemic damages
by intensive care therapy
ANTIBIOTIC THERAPY

Is directed against an aerobic &

anaerobic pathogen
Requires a sufficiently high
concentration at the side infection
Has few side effect
Does not infringe on the bodys
defenses
Evidence base
THE CHOICE OF ANTIBIOTIC
depends on:

The expected organism,based on

the source of infection
The estimate of AB susceptibility of
the expected organism
The extent of contamination
The hemodynamic stability of the
patient
BACTERIAL CONCENTRATION

The use of H-2 blockers or proton pump

inhibitor can increase the bacterial
concentration in the stomach
Long standing bowel obstruction can increase
bacterial concentration in upper GI tract
The bacterial concentration of the colon is
diminished by bowel preparation
The consequences of perforation of different
part of GI tr. relate to differences in bacterial
concentration
INTRA ABDOMINAL ABSCESS

Caused by predominantly by
anaerobes
Single drug therapy, Cephalosporin
with activity against anaerobes
Combination with anaerobic
coverage antibiotic(Metronidazole,
Clindamycine)
Extended-Spectrum -
Lactamases
Detected mainly in klebsiellae and E. coli
Recently described in P. mirabilis, C. freundii,
E. aerogenes
Confer resistance to 3rd & 4th generation
cephalosporins & aztreonam
Frequent co-resistance to quinolones and
aminoglycosides
Usually inhibitor susceptible
 SENTRY Surveillance Program 1997-99
ESBL in E.coli
50

40

30
%
ESBL
20

10 8.5 7.9
4.2 5.3

0
US n=1203 Latin America Europe n=3822 Asia-Pacific
n=2026 n=1104

Winokur PL. Clin Infect Dis 2001;32(suppl. 2):S94

 Solutions for
Beta-Lactamase-Mediated Resistance

Beta-lactamase inhibitor combinations

Effective for ESBL- producing bacteria
Relatively cheap
Carbapenems
Unnecessarily broad-spectrum antibiotics
Expensive
Should be reserved for documented resistance
-Lactamase Inhibitors

Clavulanic acid
Amoxicillin
Ticarcilin
Sulbactam
Ampicillin
Cefoperazone
Tazobactam
Piperacillin
 Cefoperazone /Sulbactam
Clinical use
Hospital-acquired pneumonia
Intraabdominal infections
Obstetrical and gynecological infections
Pelviperitonitis
Pelvic abscess
Intrauterin infections
Febrile neutropenia
Nosocomial UTI
Noscomial skin & soft-tissue infections
Pediatric infections
 Cefoperazone-Sulbactam vs Clindamycin +
Gentamicin in Intraabdominal Infections
100
Cef/Sulb
110/152 evaluable
80 * Clinda+Genta patients
Cef/Sulb 3 g bid
60
* Clinda 2400 mg/d +genta
% * p<0.006 4.5-6mg/kg day in 4
pts40 doses
20 336 aerobic isolates
91% suceptible to cef/sulb
0 85% to clinda + genta
Cured Imp Failed 112 anaerobes
95% suceptible to all 3
antibiotics
Jauregui LE, et al. JAC 1990;25:423-33
Cefoperazone-Sulbactam
in Biliary Infections
Open, prospective, multicenter trial
273/338 patients evaluable
127 cholecystitis
132 cholangitis
14 liver abscesses
93 patients (34%) had malignancy
Overall efficacy 80%
89%, cholecystitis In pts w malignancy, 63%

77%, cholangitis In those w/o malignancy,

88%
21%, abscesses (p<0.05)
Shinagawa N, et al. Jpn J Antibiot 1997;50:862
SURGICAL ANTIBIOTIC
PROPHYLAXIS

The efficiacy is unquestioned

Marked reduction in wound infection rate
have been documented over the past 30
years
Most effective when the antibiotic is
present in tissue before the skin incision
is made
The cephalosporins are the drug of
choices for prohylaxis of the vast
majority of operative procedure
 LAPAROSCOPIC SURGERY
IN INTRA ABDOMINAL
INFECTION
Confirm/correct the preoperative
diagnostic

Surgical treatment

Intra abdominal suction-irrigation

Acute appendicitis with abscess
Acute cholecystitis
LAPAROSCOPY IN ABDOMINAL
INFECTION
DIAGNOSIS N
Acute Cholecystitis

Empyema gall bladder 19

Perivesical abscess 5

Subphrenic abscess 1

Subhepatic abscess 2
Acute Appendicitis
Periapp mass with abscess formation 2
Perforation 2
Total 31
 ANTIBIOTIC TREATMENT
- 31 patients ( mean age: 49 yrs)
- Acute cholecystitis & acute appendicitis
- Antibiotic Sulbactam-Cefoperazon
- 2 gr before skin incision, daily dose 2 gr
in two doses
- Average duration of treatment 3 days
(range 2-5 days)
- Surgical site infection: nil
 CONCLUSION
Combination of timely surgical intervention,
appropriate antibiotic therapy and normal host
defense mechanism result in complete resolution of
the infection and subsequent recovery
Antibiotic play an integral role in preparation of a
patient for operation
Administration of antibiotic that are active against
both aerobes and anaerobes is generally to be the
gold standard.Have to be cautious of ESBL in E.coli