What is the appropriate antibiotic coverage for sepsis secondary to intra-abdominal infection (Intra-Abdominal Infection)?

From the Guidelines

For sepsis secondary to intra-abdominal infection, initiate broad-spectrum antibiotic therapy immediately with a combination of piperacillin-tazobactam and vancomycin, as recommended by the Surviving Sepsis Campaign guidelines 1.

Recommended Antibiotic Regimen

• Piperacillin-tazobactam 4.5g IV every 6 hours
• Plus vancomycin 15-20 mg/kg IV every 8-12 hours (dose based on actual body weight)

This regimen provides coverage for gram-negative bacteria (including Pseudomonas), gram-positive bacteria (including MRSA), and anaerobes. In critically ill patients or those with risk factors for resistant organisms, consider adding an antifungal such as fluconazole 800 mg IV loading dose, followed by 400 mg daily.

Rationale

The choice of empiric antimicrobial regimen in sepsis and septic shock is complex and cannot be reduced to a simple table 1. However, the recommended regimen of piperacillin-tazobactam and vancomycin is supported by guidelines from the Surgical Infection Society and the Infectious Diseases Society of America 1.

Key Considerations

• Adjust antibiotics based on culture results, typically continuing for 5-7 days total. Longer durations may be necessary for inadequate source control or immunocompromised patients.
• Obtain prompt surgical consultation for source control, which is crucial in managing intra-abdominal infections.
• Consider the patient's underlying diseases, chronic organ failures, medications, indwelling devices, and immunosuppression status when selecting an empiric antimicrobial regimen 1.

Evidence-Based Recommendation

The recommended regimen is based on the most recent and highest-quality study available, which emphasizes the importance of broad-spectrum antibiotic coverage in sepsis secondary to intra-abdominal infection 1.

From the FDA Drug Label

One controlled clinical study of complicated intra-abdominal infection was performed in the United States where meropenem was compared with clindamycin/tobramycin. Three controlled clinical studies of complicated intra-abdominal infections were performed in Europe; meropenem was compared with imipenem (two trials) and cefotaxime/metronidazole (one trial)

The appropriate antibiotic coverage for sepsis secondary to intra-abdominal infection includes meropenem, which has been compared to other antibiotics such as clindamycin/tobramycin, imipenem, and cefotaxime/metronidazole in clinical studies 2.

• Meropenem was found to have a microbiologic eradication rate of 67% and a clinical cure rate of 69% in the evaluable population with complicated intra-abdominal infection.
• The clinical efficacy of meropenem was also compared to imipenem and cefotaxime/metronidazole in other studies, demonstrating its effectiveness in treating complicated intra-abdominal infections.
• Another option is the combination of cefepime plus metronidazole, which was compared to imipenem/cilastatin in a randomized, double-blind, multicenter trial, showing an overall clinical cure rate of 81% in the protocol-valid patients 3.

From the Research

Antibiotic Coverage for Sepsis Secondary to Intra-Abdominal Infection

• The choice of antibiotic therapy for sepsis secondary to intra-abdominal infection should be based on the kind of infection, local resistances, and patient's characteristics and comorbidities 4.
• Piperacillin/tazobactam is an effective treatment for patients with intra-abdominal infections, including those with sepsis or septic shock 5, 6.
• Combination regimens of piperacillin/tazobactam plus an aminoglycoside can be used to treat patients with severe nosocomial infections 5.
• Antibiotic Stewardship Programs (ASP) have demonstrated to improve antimicrobial utilization with reduction of infections, emergence of multi-drug resistant bacteria, and costs 4.
• The most appropriate antibiotic regimen for patients with community-acquired abdominal infection should consider effectiveness, safety, cost, and antibiotic resistance 7.

Recommended Antibiotic Regimens

• Piperacillin/tazobactam or imipenem should be used empirically in patients presenting with complicated intra-abdominal infections secondary to perforated viscus, especially if they have sepsis or septic shock 6.
• Ceftriaxone-metronidazole, ampicillin-sulbactam, piperacillin-tazobactam, and ertapenem are favored regimens for the treatment of abdominal sepsis acquired in the community 7.
• A shorter duration of antimicrobial treatment (four or less days) is recommended for adult patients with complicated intra-abdominal infections who have undergone definitive source control 8.