Abscess , intra-abdominal

Signs and Symptoms Depend on the site of infection. Infection may produce osteomyelitis or arthritis pneumonia [with chills, productive cough, low blood pressure (hypotension), difficulty breathing (dyspnea), or chest pain] meningitis or cerebral abscesses (with headache, fever, vomiting, stupor, coma) or intra-abdominal infections (with biliary drainage, hepatic abscess, pancreatic abscess, peritoneal exudate). 

Life-threatening infections - The IV route may be preferable for patients with bacterial septicemia, localized parenchymal abscesses (such as intra-abdominal abscess), peritonitis or other severe or life-threatening infections. 

IV route IV route is recommended for patients requiring single doses greater than 1 g or those with bacterial septicemia, localized parenchymal abscess (eg, intra-abdominal abscess), peritonitis, or other severe systemic or life-threatening infections. For infections due to P. aeruginosa, a dosage of 2 g every 6 or 8 hours is recommended, at least upon initiation of therapy. 

Anaerobes Serious respiratory tract infections such as empyema, anaerobic pneumonitis, and lung abscess serious skin and soft tissue infections septicemia, intra-abdominal infections such as peritonitis and intra-abdominal abscess (typically resulting from anaerobic organisms resident in the normal Gl tract) infections of the female pelvis and genital tract such as endometritis, nongonococcal tubo-ovarian abscess, pelvic cellulitis, and postsurgical vaginal cuff infection. 

Candidemia and other Candida infections For the treatment of candidemia and the following Candida infections intra-abdominal abscesses, peritonitis, and pleural space infections. 

Therapy should be streamlined as soon as microbiological test results become available. If defervescence takes longer than a week physical and radiological examination (ultrasound or CT-scan of the abdomen) should be performed to exclude an intra-abdominal- or liver-abscess. 

Prompt diagnosis of intra-abdominal infections or of abscess formation elsewhere in the body by liberal use of ultrasound and other imaging techniques should lead to subsequent surgical treatment without delay. Soft tissue infections (superficial and deep) can have a dramatic clinical course. Timely diagnostic imaging and surgical treatment will equally reduce morbidity and mortality. 

Metronidazole is indicated for treatment of anaerobic or mixed intra-abdominal infections, vaginitis (trichomonas infection, bacterial vaginosis), C difficile colitis, and brain abscess. The typical dosage is 500 mg three times daily orally or intravenously (30 mg/kg/d). Vaginitis may respond to a single 2-g dose. A vaginal gel is available for topical use. 

To treat polymicrobial infections such as intra-abdominal abscesses. The antimicrobial combination chosen should cover the most common known or suspected pathogens but need not cover all possible pathogens. The availability of antimicrobials with excellent polymicrobial coverage (eg, 13-lactamase inhibitor combinations or imipenem) may reduce the need for combination therapy in the setting of polymicrobial infections. 

Treatment of sepsis to which anaerobic organisms, e.g. Bacteroides spp. and anaerobic cocci, are contributing, notably postsurgical infection, intra-abdominal infection and septicaemia, but also woimd and pelvic infection, osteomyelitis and abscesses of brain or lung... 

Crohn s disease may be complicated by intestinal strictures, fistulae and intra-abdominal abscesses. Surgery is often necessary but strictures may be amenable to endoscopic balloon dilatation and abscesses can be drained under radiographic control. 

MN is a 54-year-old man who was diagnosed with an intra-abdominal abscess after sustaining a stab wound. He is started on a 21-day course of cefotetan. His social history includes drinking two beers per night. His PMH is significant for peptic ulcer disease, HTN, and seasonal allergies. His medications include omeprazole, enalapril, and cetirizine. Which of the following statements are correct ... 

Most serious adverse effect (2% incidence, idiosyncratic) is Gl bleeding or perforation, sometimes with intra-abdominal abscess formation impaired wound healing hypertension proteinuria rare severe pulmonary hemorrhage... 

Caspofungin is indicated in the treatment of invasive aspergillosis in patients refractory to, or intolerant of, other antifungal therapies empirical treatment for presumed fungal infections in febrile, neutropenic patients treatment of esophageal candidiasis treatment of candidemia and the following Candida infections intra-abdominal abscesses, peritonitis, and pleural space infections. 

Intra-abdominal infections, including acute cholecystitis, cholangitis, peritonitis, hepatic abscess, and intra-abdominal abscess caused by susceptible E. coli, P. mirabilis, Klebsiella sp.. 

Intra-abdominal infections including peritonitis and intra-abdominal abscess caused by E. coli,... 

Antibiotics can be used as either (1) adjunctive treatment along with other medications for active IBD (2) treatment for a specific complication of Crohn s disease or (3) prophylaxis for recurrence in postoperative Crohn s disease. Metronidazole, ciprofloxacin, and clarithromycin are the antibiotics used most frequently. They are more beneficial in Crohn s disease involving the colon than in disease restricted to the Ueum. Specific Crohn s disease-related complications that may benefit from antibiotic therapy include intra-abdominal abscess and inflammatory masses, perianal disease (including fistulas and perirectal abscesses), small bowel bacterial overgrowth secondary to partial small bowel obstruction, secondary infections with organisms such as Clostridium difficile, and postoperative complications. Metronidazole may be particularly effective for the treatment of perianal disease. Postoperatively, a 3-month course of metronidazole (20 mg/kg/day) can prolong the time to both endoscopic and clinical recurrence. 

Treatment of Polymicrobial Infections. Treatment of intra-abdominal, hepatic, and brain abscesses, and some genital tract infections may require the use of a drug combination to eradicate these typically mixed aerobic-anaerobic infections. These and other mixed infections may be caused by two or more different microorganisms that are sufficiently different in antibiotic sensitivity that no single agent can provide the required coverage. 

Abdominal ultrasound (US), thanks to its accuracy, good repeatability and non-invasiveness is currently employed in many chronic inflammatory conditions, not only for purely diagnostic purposes, but also for management of the disease. In Crohn s disease (CD) patients, US has become the first-line imaging procedure for early diagnosis of the disease (Parente et al. 2004a), and more frequently for the follow-up, to detect intra-abdominal complications (strictures, fistulae and abscesses), to assess activity and monitor the course of disease, as a prognostic index of recurrence (Table 7.1). 

The US manifestations of CD reflect the pathological features, consisting of abnormalities of bowel wall or representing its intra-abdominal complications. The abnormalities of bowel wall include bowel wall thickening, alterations of bowel wall echo pattern, hyper-aemia, loss of elasticity and peristalsis, mesentering hypertrophy and mesenteric lymph nodes. Intraabdominal complications of CD typically include stenoses and obstruction, fissures and fistulae, as well as inflammatory masses (phlegmon or abscesses). 

US detection of intra-abdominal abscesses shows a mean sensitivity and specificity of 91.5% and 93%,... 

Fig. 7.1 la,b. Intra-abdominal abscesses (A) appearing as hypo-anechoic lesions, often originating from a fistula (arrows), with irregular wall, internal echoes due to presence of debris or air, and characterised by posterior echo-enhancement... 

Maconi G, Sampietro GM, Parente F et al (2003b) Contrast radiology, computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohn s disease a prospective comparative study. Am J Gastroenterol 98 1545-1555... 

In the majority of cases, tuboovarian abscesses (TOA) result from pelvic inflammatory disease. It is reported to complicate PID in up to one-third of patients hospitalized for treatment [6]. Other etiologies include complications of surgery or intra-abdominal inflammatory bowel diseases, such as appendicitis, diverticulitis, or Crohn disease. In most cases, TOA is caused by a polymicrobial infection with a high prevalence of anaerobes. lUD users, especially in the first few months after insertion, are also under a higher risk of PID. Pelvic actinomycosis is considered to be highly associated with the use of lUD [1]. 

A 72-year-old woman developed dysarthria, dysmetria, and gait ataxia after taking metronidazole for 3 weeks for an intra-abdominal abscess. The cerebellar syndrome resolved gradually after withdrawal of metronidazole [21 ]. 

A 38-year-old woman undergoing laparotomy with removal of intra-abdominal abscess following a duodenectomy developed acute lung injury after switching from sufentanil to morphine 0.1 mg/kg/hour her symptoms developed within 3-4 hours and resolved after withdrawal of morphine [108 ]. 

Once the diagnosis of nosocomial pneumonia has been established, several important factors must be considered before a rational empirical antimicrobial regimen can be chosen. These include severity of illness and comorbid conditions of the patient, prior antibiotic use, early versus late onset of infection, results of the sputum Gram s stain, and the resident flora profile of the institution, particularly in the intensive care unit (Table 1). Empirical antimicrobial therapy for nosocomial pneumonia in a ventilated patient with renal failure in whom multiple intra-abdominal abscesses develop following colon resection is very different from the patient who aspirates following an otherwise uncomplicated cholecystectomy. 

Bile leak with resultant biloma and intra-abdominal infection with abscess formation can occur following reduced-sized, split and living related liver transplantation due to leak from the parenchymal cut-surface or inadvertent bile duct injury. Biliary reconstruction is by Roux-en-Y hepaticojejunostomy, and may involve two anastomoses at implantation of the left lateral segment at split or living related liver transplantation if segment II and III ducts are sepa-... 

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