What are the Infectious Diseases Society of America (IDSA) guidelines for managing intrabdominal infections?

From the Guidelines

The Infectious Diseases Society of America (IDSA) guidelines for intra-abdominal infections recommend a combination of early source control through surgical or percutaneous drainage plus appropriate antimicrobial therapy, with the goal of minimizing morbidity, mortality, and improving quality of life. For mild to moderate community-acquired infections, single-agent therapy with ticarcillin-clavulanate, cefoxitin, ertapenem, moxifloxacin, or tigecycline is recommended, or combinations of metronidazole with cefazolin, cefuroxime, ceftriaxone, cefotaxime, levofloxacin, or ciprofloxacin 1. Key considerations in managing intra-abdominal infections include:

• Early source control through surgical or percutaneous drainage
• Appropriate antimicrobial therapy based on the severity and origin of the infection
• Coverage for obligate anaerobic bacilli in distal small bowel, appendiceal, and colon-derived infections
• Avoidance of empiric antifungal therapy for Candida in adult and pediatric patients with community-acquired intra-abdominal infection
• Routine aerobic and anaerobic cultures from lower-risk patients with community-acquired infection are considered optional, but may be of value in detecting epidemiological changes in resistance patterns and guiding follow-up oral therapy 1. The choice of antimicrobial therapy should be based on local microbiologic data, cost advantage, allergies, and formulary availability, with the goal of providing adequate coverage against the polymicrobial nature of intra-abdominal infections while minimizing resistance development and adverse effects from unnecessarily prolonged therapy 1. In terms of specific antimicrobial regimens, the use of ticarcillin-clavulanate, cefoxitin, ertapenem, moxifloxacin, or tigecycline as single-agent therapy is preferable to regimens with substantial anti-Pseudomonal activity 1. For high-risk or severe community-acquired infections, broader coverage is advised with piperacillin-tazobactam, meropenem, imipenem-cilastatin, doripenem, or ceftazidime/cefepime plus metronidazole, while healthcare-associated infections require coverage for resistant organisms with combinations like meropenem, imipenem-cilastatin, doripenem, piperacillin-tazobactam, ceftazidime or cefepime plus metronidazole, with possible addition of vancomycin for MRSA coverage or an echinocandin for fungal coverage 1. Treatment duration should typically be 4-7 days, provided adequate source control is achieved, with longer courses needed for inadequate source control or immunocompromised patients, and antimicrobial therapy should be narrowed based on culture results when available 1.

From the Research

IDSA Guidelines for Managing Intrabdominal Infections

• The Infectious Diseases Society of America (IDSA) guidelines for managing intrabdominal infections were updated in 2011, but the provided text does not specify the exact recommendations 2.
• However, the guidelines present recommendations for the treatment of complicated intra-abdominal infections, including community-acquired and health care-associated infections 2.
• The guidelines have been criticized for not providing clear therapeutic recommendations for specific clinical diagnoses, such as primary, secondary, and tertiary peritonitis 2.

Key Principles of Managing Intrabdominal Infections

• Prompt identification, diagnosis, and treatment of intra-abdominal infections are crucial, including resuscitation, early antibiotic administration, and source control 3.
• Antibiotic administration should initially be broad-spectrum and target the most likely pathogens, with subsequent narrowing and limitation of duration based on culture results 3.
• The method of source control depends on the anatomic site, site accessibility, and the patient's clinical condition 3.

Updated Guidelines

• The Surgical Infection Society (SIS) published an updated guideline on the management of intra-abdominal infection in 2024, which includes recommendations on antimicrobial agent selection, timing, route of administration, duration, and de-escalation 4.
• The guideline also provides recommendations on the treatment of specific pathogens, specific intra-abdominal disease processes, and implementation of hospital-based antimicrobial agent stewardship programs 4.

Antimicrobial Therapy

• Early adequate empiric antimicrobial therapy is essential for managing intra-abdominal infections, and multiple empirical regimens have been proposed 5.
• The choice of initial antibiotic therapy can impact patient outcomes, with inappropriate choices resulting in longer hospital stays and higher costs 6.