What are the recommended antibiotics for gastric perforation?

From the Guidelines

For gastric perforation, the recommended antibiotic regimen is broad-spectrum coverage with a combination of antibiotics, such as piperacillin-tazobactam 3.375g IV every 6 hours, combined with metronidazole 500mg IV every 8 hours for anaerobic coverage, and an aminoglycoside like gentamicin (5-7mg/kg IV daily) for gram-negative coverage, as suggested by 1. The management of gastric perforation requires prompt initiation of antibiotics to prevent and treat peritonitis and sepsis, which are life-threatening complications of gastric contents spilling into the peritoneal cavity.

• The choice of antibiotics may need modification based on local resistance patterns, patient allergies, and renal function, as indicated by 1 and 1.
• Alternative regimens include carbapenems such as meropenem 1g IV every 8 hours or imipenem 500mg IV every 6 hours as single-agent therapy, as mentioned in 1 and 1.
• Antibiotics should be started as soon as the diagnosis is suspected and continued for 3-5 days after surgical repair, adjusting based on culture results and clinical response, as recommended by 1 and 1.
• Surgical repair of the perforation is the definitive treatment in most cases, and antibiotics are only one component of management, as stated in 1. Key considerations in the management of gastric perforation include:
• Prompt initiation of broad-spectrum antibiotics
• Surgical consultation and potential repair
• Intravenous fluids and nothing by mouth (NPO) status
• Nasogastric tube (NGT) placement, as suggested by 1
• Monitoring for signs of peritonitis and sepsis, and adjusting the antibiotic regimen as needed based on culture results and clinical response.

From the FDA Drug Label

The recommended dosage schedule for Adults is: Loading Dose 15 mg/kg infused over one hour (approximately 1 g for a 70-kg adult). Maintenance Dose 7. 5 mg/kg infused over one hour every six hours (approximately 500 mg for a 70-kg adult). For surgical prophylactic use, to prevent postoperative infection in contaminated or potentially contaminated colorectal surgery, the recommended dosage schedule for adults is:a 15 mg/kg infused over 30 to 60 minutes and completed approximately one hour before surgery, followed by:b. 7. 5 mg/kg infused over 30 to 60 minutes at 6 and 12 hours after the initial dose One controlled clinical study of complicated intra-abdominal infection was performed in the United States where meropenem was compared with clindamycin/tobramycin.

The recommended antibiotics for gastric perforation are:

• Metronidazole: 15 mg/kg infused over one hour, followed by 7.5 mg/kg infused over one hour every six hours 2
• Meropenem: 500 mg administered intravenously every 8 hours, as used in the treatment of complicated intra-abdominal infections 3 Key points:
• Metronidazole is used for the treatment of anaerobic infections and can be used for surgical prophylaxis in contaminated or potentially contaminated colorectal surgery.
• Meropenem is used for the treatment of complicated intra-abdominal infections and has been compared to other antibiotics such as clindamycin/tobramycin in clinical studies.

From the Research

Gastric Perforation Antibiotics

• The recommended antibiotics for gastric perforation are not explicitly stated in the provided studies, but some studies suggest the use of broad-spectrum antibiotics such as cefoxitin 4 or ceftriaxone plus metronidazole 5.
• For colorectal procedures, an orally administered three-dose regimen of neomycin/erythromycin is recommended, while parenteral antibiotic administration is generally not necessary, but cefoxitin is recommended for nonelective colorectal surgery 4.
• In cases of penetrating abdominal trauma without colonic perforation, antibiotic therapy that includes activity against aerobes and anaerobes is recommended, while cefoxitin is recommended as a single-drug alternative to the standard clindamycin/gentamicin regimen in trauma with colonic perforation 4.
• Single-drug therapy with cefoxitin or moxalactam can be used successfully as alternatives to the standard regimens of clindamycin/gentamicin or metronidazole/gentamicin in many patients with intraabdominal sepsis 4.
• The use of empiric anti-fungal therapy in the treatment of perforated peptic ulcer disease is not recommended, as current data suggest it fails to improve outcomes 6.

Specific Antibiotic Regimens

• cefoxitin: recommended for nonelective colorectal surgery 4 and as a single-drug alternative to the standard clindamycin/gentamicin regimen in trauma with colonic perforation 4.
• ceftriaxone plus metronidazole: compared to anti-pseudomonal antibiotics, this regimen did not differ in post-operative complication rates for children with perforated appendicitis 5.
• neomycin/erythromycin: recommended for colorectal procedures 4.
• clindamycin/gentamicin: standard regimen for intraabdominal sepsis, but single-drug therapy with cefoxitin or moxalactam can be used as alternatives 4.