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Current concepts in clinical therapeutics: intra-abdominal infections
Abstract:
The etiology, pathophysiology, clinical presentation, and treatment of the two major types of intra-abdominal infections--peritonitis and abscesses--are described. Peritonitis of infectious origin is the acute response of the peritoneum to microorganisms; it is classified as primary (when the source of bacteria is not apparent) or secondary (usually involving perforation of a hollow structure of the GI tract with subsequent release of microbes). Peritonitis results in mortality because of fluid shifts and endotoxins that may cause hypovolemia and shock. Abscesses, purulent collections of fluid physically separated from the surrounding tissues, are the result of chronic inflammation following failure of the body to eradicate a pathogen completely. Secondary intra-abdominal infections are often polymicrobial because of the diversity of organisms in the GI tract. The size of bacterial inocula and the number and types of species present substantially affect patient outcome. The patient with peritonitis usually presents in acute distress, with generalized abdominal pain and faint bowel sounds. The presentation of the patient with intra-abdominal abscess is more variable and less dramatic; pain and fever may be present. The treatment of these infections requires the coordinated use of prompt surgical intervention, support of vital functions, and appropriate antimicrobial therapy. Surgical procedures are used to stop continuing bacterial contamination of the peritoneum, remove foreign material from the abdomen, and drain purulent collections; it is the foundation of treating most types of intra-abdominal infections. Aggressive fluid therapy is required to assure adequate intravascular volumes in most patients. Generally, antimicrobial coverage for both aerobes and anaerobes must be started before culture results are available. Antimicrobial therapy for specific types of infections is given in the article. Surgical procedures are the foundation of treatment of most intra-abdominal infections; antimicrobial agents active against aerobic gram-negative bacilli and anaerobes are important adjuncts.
Insights
Intra-abdominal infections like peritonitis and abscesses require prompt surgical intervention, fluid resuscitation, and broad-spectrum antibiotics. Early diagnosis and coordinated treatment are crucial for patient survival and recovery.
Area of Science:
- Infectious Diseases
- Surgical Gastroenterology
- Critical Care Medicine
Background:
- Intra-abdominal infections (IAIs) encompass peritonitis and abscesses, posing significant clinical challenges.
- Peritonitis involves acute peritoneal inflammation, while abscesses represent localized, chronic collections of pus.
- Secondary IAIs are frequently polymicrobial, originating from gastrointestinal tract perforations.
Purpose of the Study:
- To describe the etiology, pathophysiology, clinical presentation, and treatment of peritonitis and abscesses.
- To highlight the critical role of surgical intervention and antimicrobial therapy in managing IAIs.
- To emphasize the impact of bacterial load and species on patient outcomes.
Main Methods:
- Review of the literature on the pathogenesis and clinical management of intra-abdominal infections.
- Description of diagnostic presentations for peritonitis and abscesses.
- Outline of treatment strategies including surgery, fluid management, and antimicrobial selection.
Main Results:
- Peritonitis can lead to hypovolemia and shock due to fluid shifts and endotoxins.
- Abscess presentation is variable, often with pain and fever.
- Effective treatment necessitates surgery to control contamination and drain pus, alongside supportive care and antibiotics.
Conclusions:
- Surgical procedures form the cornerstone of managing most intra-abdominal infections.
- Aggressive fluid resuscitation is vital for hemodynamic stability.
- Empirical antimicrobial therapy targeting both aerobic and anaerobic bacteria is essential prior to culture results.