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Choosing antibiotics for intra-abdominal infections: what do we mean by "high risk"?
Brian R Swenson1, Rosemarie Metzger, Traci L Hedrick
1Department of Surgery, University of Virginia, Charlottesville, Virginia 22908-0709, USA.
Background:
The definition of "high risk" in intra-abdominal infections remains vague. The purpose of this study was to investigate patient characteristics associated with a high risk of isolation of resistant pathogens from an intra-abdominal source.
Methods:
All complicated intra-abdominal and abdominal organ/space surgical site infections treated over a ten-year period in a single hospital were analyzed. Infections were categorized by pathogen(s). Organisms designated "resistant" were those that had a reasonable probability of being resistant to the broad-spectrum agents imipenem/cilastatin and piperacillin/tazobactam, and included non-fermenting gram-negative bacilli (e.g., Pseudomonas aeruginosa), resistant gram-positive pathogens, vancomycin-resistant enterococci, and fungi. Patient characteristics were analyzed to define associations with the risk of isolation of "resistant" pathogens.
Results:
A total of 2,049 intra-abdominal infections were treated during the period of study, of which 1,182 had valid microbiological data. The two genera of pathogens isolated from more than 25% of health care-associated infections and more commonly than from community-acquired infections were Enterococcus spp. (29%) and Candida spp. (33%). Health care association, corticosteroid use, organ transplantation, liver disease, pulmonary disease, and a duodenal source all were associated with resistant pathogens. By multivariable analysis, several acute and chronic measures of disease were predictive of death, with a strong interaction between solid organ transplantation, resistant pathogens, and death. Other links between specific pathogens and patient characteristics were documented, for example, between fungal infection and a gastric, duodenal, or small bowel source, and between liver transplantation and vancomycin-resistant enterococci.
Conclusions:
On the basis of clinical characteristics, it may be possible to identify patients with intra-abdominal infections caused by pathogens that are potentially resistant to broad-spectrum antibacterial agents. Under these circumstances, and if warranted clinically, broadened coverage probably ought to include specific anti-enterococcal and anti-candidal therapy.
Insights
Identifying patients with intra-abdominal infections at high risk for resistant pathogens is crucial. Clinical factors can help predict the need for broader antibiotic coverage, including anti-enterococcal and anti-candidal therapies.
Area of Science:
- Infectious Diseases
- Clinical Microbiology
- Surgical Infections
Background:
- Intra-abdominal infections (IAIs) pose a significant clinical challenge.
- The definition of
- high risk
- for IAIs remains unclear.
- Identifying patients at risk for resistant pathogens is critical for effective treatment.
Purpose of the Study:
- To investigate patient characteristics associated with a high risk of isolating resistant pathogens from intra-abdominal sources.
- To refine the definition of
- high risk
- in the context of IAIs.
Main Methods:
- Analysis of complicated IAIs and surgical site infections over a ten-year period.
- Categorization of infections by pathogen(s), defining "resistant" organisms.
- Patient characteristics were analyzed for associations with resistant pathogen isolation.
Main Results:
- Enterococcus spp. (29%) and Candida spp. (33%) were common in health care-associated IAIs.
- Health care association, corticosteroid use, organ transplantation, liver disease, pulmonary disease, and duodenal source predicted resistant pathogens.
- Solid organ transplantation, resistant pathogens, and death showed a strong interaction.
Conclusions:
- Clinical characteristics can identify patients with IAIs caused by potentially resistant pathogens.
- Broader antibiotic coverage, including anti-enterococcal and anti-candidal therapy, may be warranted.
- This aids in optimizing treatment strategies for high-risk IAIs.
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