Tutorial clinical cases for Intra-abdominal infections

1. Intar-abdomial
infections Cases
Dr. Sameh Ahmad Muhamad abdelghany
Lecturer Of Clinical Pharmacology
Mansura Faculty of medicine

2. Intra-abdominal
Infections

3. CAS(1)

4. Chief Complain
4
A“My belly hurts so bad I can barely move.”.

5. Present History
5
John Chavez is a 67-year-old Hispanic man who was
brought to the ED by his wife. She stated that he has
been suffering from nausea, vomiting, severe
abdominal pain. His intake of food and fluids has been
minimal over the past several days. He is a well-known
patient of the ED who often presents with severe
hepatic encephalopathy.

6. PAST HISTORY
6
Cirrhosis with ascites for the last 4 years Hepatic
encephalopathy
Spontaneous bacterial peritonitis—one episode 9 months
ago

7. PHYSICAL EXAMINATION
7
General:
 Elderly man who appears older than his stated age
and is in severe pain
Vital Signs
 BP 154/82, P 102, RR 32, T 38.2°C
Skin
 Jaundiced, warm, coarse, and very dry.

8. PHYSICAL EXAMINATION
8
Abdominal examination:
 Abd Distended; pain upon pressure or movements
 Pain is sharp and diffuse throughout abdomen
 Decreased bowel sounds.
The remainder of his physical examination is
unremarkable.

9. LABORATORY
9
 Blood Cultures
 Pending 2
 Paracentesis
 Ascitic fluid: leukocytes 720/mm3, protein 2.8 g/dL,
albumin 1.6 g/dL, pH 7.28, lactate 30 mg/dL.
 Gram-stain: +ve organism

10. LABORATORY
10
 Abdominal X-Ray:
 No evidence of free air
 Chest X-Ray:
 No infiltrates; heart normal size and shape

11. 11
Assessment
 Primary bacterial peritonitis.

12. Questions
12
Q1. What signs, symptoms, and laboratory values
indicate the presence of primary bacterial
peritonitis?
Q2: What risk factors for infection are present in
this patient?
Q3: Which organisms are the most likely cause of
this infection?

13. Questions
13
Q4. What are the therapeutic goals for this patient?
Q5: Given this patient’s condition, which drug
regimens would provide optimal therapy for the
infection?

14. Answer of Question 1
14
 Abdominal pain,Nausea/Vomiting,Loss of Appetite
 Fever (38-40 ºC)
 Abdominal distention and tenderness
 Abdominal examination:Abd Distended; pain upon pressure or
movements,Pain is sharp and diffuse throughout
abdomen,Decreased bowel sounds.
 Ascitic fluid: leukocytosis & Gram-stain: +ve organism
Back

15. Answer of Question 2
15
 Liver disease (cirrhosis)
 Fluid in the abdomen
Back

16. Answer of Question 3
16
 Escherichia coli
 Streptococci
 Enterococci
 Klebsiella
 Staphylococci
 Pseudomonas aeruginosa
 Bacteroides sp.
Back

17. Answer of Question 4
17
Support of Vital functions:
 Blood pressure/fluid replacement,
 Monitor heart rate
 Monitor urine out put (0.5 ml/kg/hr)
Give Appropriate antimicrobial therapy
Paracentesis for ascitic fluid
Back

18. Answer of Question 5
18
 Start Empiric Antibiotic Therapy
 MUST include aerobic/anaerobic coverage
 Aerobic and Anaerobic activity e.g Ampicillin/sulbactam (Unasyn)
,Piperacillin/tazobactam (Zosyn) ,Cefotetan (Cefotetan),Imipenem/cilastin
(Primaxin)
 Improvement in 2 to 3 days
 Switch for oral antibiotic therapy
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19. CAS(2)

20. Scenario
20
 John Romans is a 34-year-old male who presents to the
emergency department complaining of acute onset of severe
abdominal pain, localized in the periumbilical region. The patient
states that his persistent fever and a localized region of pain in
his abdomen are new symptoms for him. His oral intake has
decreased over the past week due to the pain. He has a past
medical history significant for Crohn’s disease, which was
diagnosed 15 years ago.

21. Scenario
21
 Malaise and fever for a couple of days despite use of
acetaminophen; abdomen tender right of umbilicus with
palpable mass that has developed over past few days;
abdomen pain increases with eating; (–) significant
weight loss

22. Scenario
22
 Microbiologic Data
 Blood cultures pending
Imaging
 Abdominal CT shows evidence of abdominal wall
abscess arising from terminal ileum.

23. Questions
23
 Q1. What characteristics of the patient’s case are consistent with
a secondary intra-abdominal infection?
 Q2: On the basis of the patient’s history and presentation, should
empiric antibiotic treatment cover for a monomicrobial or
polymicrobial infection?
 Q3: What are the likely pathogens on the basis of the patient’s
site of infection and underlying disease process?
 Q4: What intervention is foremost in the management of an
intra-abdominal abscess?

24. Answer of Question 1
24
 severe abdominal pain, localized in the periumbilical
region
 persistent fever and a localized region of pain
 Loss of appetite
 Abdomen tender right of umbilicus with palpable mass;
abdomen pain increases with eating
 Abdominal CT shows evidence of abdominal wall abscess
arising from terminal ileum.
Back

25. Answer of Question 2
25
 On his history of chron’s disease and development of
intra-abdominal abscess, he must be treated ploymicrobial
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26. Answer of Question 3
26
Common Bacteria:
o E. coli
o Klebsiella
o Enterococci
o B. fragilis
o Clostridium
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27. Answer of Question 4
27
 Combination of modalities:
1) Surgical:
 Prompt drainage of abscess (secondary peritonitis) and/or debridement,
2) Support of Vital functions:
 Blood pressure/fluid replacement,
 Monitor heart rate
 Monitor urine out put (0.5 ml/kg/hr)
3) Empiric Antibiotic Therapy must include aerobic/anaerobic coverage
4) Appropriate antimicrobial therapy after result of culture
Back

28. CAS(3)

29. Scenario
29
 H.M., a 33-year-old woman with HIV and end-stage
renal disease, has undergone continuous ambulatory
peritoneal dialysis (CAPD) daily for the past year. She
presents with abdominal pain and a cloudy dialysate
fluid. H.M. has negligible residual urine output.

30. Questions
30
Q1. What are the most common causative organisms
related to CAPD-associated peritonitis?
Q2: What empiric antimicrobial therapy should be
initiated?

31. Answer of Question 1
31
 Staphylococci
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32. Answer of Question 2
32
 Empiric Antibiotic Therapy MUST include
aerobic/anaerobic coverage
 Aerobic and Anaerobic activity
o Ampicillin/sulbactam (Unasyn) (enterococci)
o Piperacillin/tazobactam (Zosyn) (enterococci)
o Cefotetan (Cefotetan)

33. CAS(4)

34. Case
34
 S.R. is a 12-year-old girl with a 2-day history of
periumbilical pain migrating to the right lower
quadrant, abdominal distension, fever of 39°C,
diarrhea, and decreased bowel sounds. Her WBC
count is 15.8 ×103/μL. A presumptive diagnosis of
acute appendicitis is made.

35. Questions
35
Q1. How to manage the case?
Q2: For how long antibiotics should be
continued?

36. Answer of Question 1
36
Treatment :Both surgical & Antibiotics
I. Acute, non-perforated appendicitis
 cefazolin + metronidazole
II. Perforated appendicitis
 Anti-anaerobic cephalosporin (e.g. Cefotetan, Cefoxitin,
Piperacillin/tazobactam, Ampicillin/sulbactam, Imipenem
 Combination therapy: Aminoglycoside +/- Clindamycin or
Metronidazole
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37. Answer of Question 2
37
 Antibiotics are started before surgery, continued for 7- 10
days.
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38. T H A N K Y O U !
A N Y Q U E S T I O N S ?