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==Overview==
==Definitions==
From a clinical view, intra-abdominal infections can be classified in:<ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref><ref name="pmid19281892">{{cite journal| author=Mazuski JE, Solomkin JS| title=Intra-abdominal infections. | journal=Surg Clin North Am | year= 2009 | volume= 89 | issue= 2 | pages= 421-37, ix | pmid=19281892 | doi=10.1016/j.suc.2008.12.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19281892  }} </ref><ref name="pmid16060697">{{cite journal| author=Blot S, De Waele JJ| title=Critical issues in the clinical management of complicated intra-abdominal infections. | journal=Drugs | year= 2005 | volume= 65 | issue= 12 | pages= 1611-20 | pmid=16060697 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060697  }} </ref>
* '''Uncomplicated''', in which the infectious process involves only a single organ and there is no anatomical disruption
* '''Complicated''', in which the infectious process extends beyond the hollow viscus into the peritoneal space and is associated with abscess formation or peritonitits.
Patients with uncomplicated intra-abdominal infections usually do not need antimicrobial therapy besides perioperative prophylaxis and can be managed with surgery alone (i.e. [[appendicitis]]).
A health care-associated infection is a new term that describe patients that have a close contact with health systems, they include community-onset infection and hospital-onset infection. The following table describes the two types of health care-associated infection that would guide the therapeutic regimen. <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
! style="width: 300px;background: #4479BA"|{{fontcolor|#FFF| '''''Community-onset infection '''''}}
! style="width: 300px;background: #4479BA"|{{fontcolor|#FFF| '''''Hospital-onset infection '''''}}
|-
|  style="width: 120px;background: #F5F5F5"| Includes patients with 1 or more of the following conditions:
*The presence of an invasive device at time of admission
*History of [[MRSA]] infection or colonization
*History of surgery, hospitalization, [[dialysis]], or residence in a long-term care facility in the previous 12 months.
|  style="width: 120px;background: #F5F5F5"| Includes patients with positive culture results obtained >48 h after admission. <br> Patients might also have 1 of the conditions described in community-onset infection.
|-
|}
==Principles of Therapy for Complicated Intra-abdominal Infection==
The following table describes the factors that define a high risk infection, due to an increase chance of treatment failure and a more severe infection.<ref name="pmid8611076">{{cite journal| author=Koperna T, Schulz F| title=Prognosis and treatment of peritonitis. Do we need new scoring systems? | journal=Arch Surg | year= 1996 | volume= 131 | issue= 2 | pages= 180-6 | pmid=8611076 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8611076  }} </ref>
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
! style="width: 300px;background: #4479BA"|{{fontcolor|#FFF| '''''Clinical factors for high risk patients'''''}}
|-
|  style="width: 120px;background: #F5F5F5"| Delay in the initial intervention (>24 h)
|-
|  style="width: 120px;background: #DCDCDC"| [[APACHE II]] score ≥ 15
|-
|  style="width: 120px;background: #F5F5F5"| Advanced age (>70 years)
|-
|  style="width: 120px;background: #DCDCDC"| Comorbidity and degree of organ dysfunction
|-
|  style="width: 120px;background: #F5F5F5"| Low [[albumin]] level
|-
|  style="width: 120px;background: #DCDCDC"| Poor nutrition status
|-
|  style="width: 120px;background: #F5F5F5"| Degree of peritoneal involvement or diffuse peritonitis
|-
|  style="width: 120px;background: #DCDCDC"| Inability to achieve adequate [[debridement]] or control of drainage
|-
|  style="width: 120px;background: #F5F5F5"| Presence of [[malignancy]]
|-
|}
*All patients should undergo a source control procedure to clear infected foci.<ref name="pmid15542959">{{cite journal| author=Marshall JC, Maier RV, Jimenez M, Dellinger EP| title=Source control in the management of severe sepsis and septic shock: an evidence-based review. | journal=Crit Care Med | year= 2004 | volume= 32 | issue= 11 Suppl | pages= S513-26 | pmid=15542959 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15542959  }} </ref>
*Patients should undergo fluid resuscitation to restore cardiovascular [[homeostasis]]. For patients with septic shock, follow The Surviving Sepsis Campaign guidelines for managing septic shock.<ref name="pmid23361625">{{cite journal| author=Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM et al.| title=Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. | journal=Intensive Care Med | year= 2013 | volume= 39 | issue= 2 | pages= 165-228 | pmid=23361625 | doi=10.1007/s00134-012-2769-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23361625  }} </ref>
*If the diagnosis of intra-abdominal infection is confirmed or is considered highly likely, antibiotics should be initiated immediately.
*Patients without [[septic shock]] should receive the proper [antibiotics]] in the [[emergency department]].<ref name="pmid23361625">{{cite journal| author=Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM et al.| title=Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. | journal=Intensive Care Med | year= 2013 | volume= 39 | issue= 2 | pages= 165-228 | pmid=23361625 | doi=10.1007/s00134-012-2769-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23361625  }} </ref>
*Only cultures from the site of infection should be obtained from higher-risk patients, for patients with lower-risk community-acquired infection, cultures are optional.<ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
*Sensibility testing for ''[[Pseudomonas]]'', ''[[Proteus]]'', ''[[Acinetobacter]]'', ''[[Staphylococcus aureus]]'', and [[Enterobacteriaceae]] should be done, as this organisms have shown higher resistance rates in recent years.<ref name="pmid19748234">{{cite journal| author=Hawser SP, Bouchillon SK, Hoban DJ, Badal RE| title=In vitro susceptibilities of aerobic and facultative anaerobic Gram-negative bacilli from patients with intra-abdominal infections worldwide from 2005-2007: results from the SMART study. | journal=Int J Antimicrob Agents | year= 2009 | volume= 34 | issue= 6 | pages= 585-8 | pmid=19748234 | doi=10.1016/j.ijantimicag.2009.07.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19748234  }} </ref>
*Lower-risk patients with community-acquired intra-abdominal infection which show favorable clinical progress do not require modification of therapy.
*If microorganisms with high pathogenic potential are found, susceptibility results should be used to determine antibiotic therapy in high-severity community-acquired or health care-associated infection.
*The recommended duration of therapy is 4-7 days.<ref name="pmid14523762">{{cite journal| author=Solomkin JS, Mazuski JE, Baron EJ, Sawyer RG, Nathens AB, DiPiro JT et al.| title=Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. | journal=Clin Infect Dis | year= 2003 | volume= 37 | issue= 8 | pages= 997-1005 | pmid=14523762 | doi=10.1086/378702 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14523762  }} </ref>
*Completion of the antibiotic course with oral presentations can be considered if the patient evolves favorably, is  able to tolerate an oral diet and if his susceptibility studies do not show resistant microorganisms.<ref name="pmid9654311">{{cite journal| author=Solomkin JS, Dellinger EP, Bohnen JM, Rostein OD| title=The role of oral antimicrobials for the management of intra-abdominal infections. | journal=New Horiz | year= 1998 | volume= 6 | issue= 2 Suppl | pages= S46-52 | pmid=9654311 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9654311  }} </ref>
==Extra-biliary Complicated Intra-abdominal Infection==
===Community-Acquired===
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
{|
{|
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<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
<font color="#FFF">
'''Community-acquiered infection in pediatric patients'''
'''Children'''
</font>
</font>
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<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background:#4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Single agent'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Single agent'''
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<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background:#4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Combination'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Combination'''
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<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
<font color="#FFF">
'''Mild-to-moderate severity'''
'''Adults - Mild to Moderate'''
</font>
</font>
</div>
</div>


<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background:#4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Single agent'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Single agent'''
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</div>
</div>


<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background:#4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Combination'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Combination'''
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</div>
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<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
<font color="#FFF">
'''High risk or severity'''
'''Adults - Severe'''
</font>
</font>
</div>
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<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Single agent'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Single agent'''
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</div>
</div>


<div class="mw-customtoggle-table06" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<div class="mw-customtoggle-table06" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Combination'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Combination'''
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{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Triple therapy}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Children}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Single Antibiotic Regimen
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ertapenem]] 15 mg/kg IV q12h (max: 1g/day) <small>(for 3 mo - 12 yrs old)</small>''''' <br> ▸ '''''[[Ertapenem]] 1 g IV q24h <small>(for >13 yrs old)</small>'''''<br> OR <br> ▸ '''''[[Meropenem]] 60 mg/kg/day IV divided q8h'''''<br> OR <br> ▸ '''''[[Imipenem]]/[[Cilastatin]] 60-100 mg/kg/day IV divided q6h'''''<br> OR <br> ▸ '''''[[Ticarcillin]]-[[Clavulanate]] 200-300 mg/kg/day IV divided q4-6h <small>([[Ticarcillin]] component)</small>'''''<br> OR <br> ▸ '''''[[Piperacillin]]-[[Tazobactam]] 200-300 mg/kg/day IV divided q6-8h <small>([[Piperacillin]] component)</small>'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Children}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Combined Antibiotic  Regimen 1
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ceftriaxone]] 50-75 mg/kg/day IV divided q12-24h'''''<br> OR <br> ▸ '''''[[Cefotaxime]] 150-200 mg/kg/day IV divided q6-8h'''''<br> OR <br> ▸ '''''[[Cefepime]] 100 mg/kg/day IV divided q12h'''''<br> OR <br> ▸ '''''[[Ceftazidime]] 150 mg/kg/day IV divided q8h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 30-40 mg/kg/day IV divided q8h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Combined Antibiotic  Regimen 2
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Gentamicin]]<sup>†</sup> 3-7.5 mg/kg/day IV divided q2-4h'''''<br> OR <br> ▸ '''''[[Tobramycin]]<sup>†</sup> 3-7.5 mg/kg/day IV divided q8-24h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clarithromycin]] 500 mg q12h.'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 30-40 mg/kg/day IV divided q8h'''''<br> OR <br> ▸ '''''[[Clindamycin]] 20-40 mg/kg/day IV divided q6-8h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | WITH OR WITHOUT
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV divided q6h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=left | <small> <sup>†</sup> Antibiotic serum concentrations and renal function should be monitored</small>
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Adults - Mild to Moderate}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Single Antibiotic Regimen
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 1 g q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefoxitin]] 2 g IV q6h'''''<br> OR <br> ▸ '''''[[Ertapenem]] 1 g IV q24h'''''<br> OR <br> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''<br> OR <br> ▸ '''''[[Tigecycline]] 100 mg initial dose, then 50 mg IV q12h'''''<br> OR <br> ▸ '''''[[Ticarcillin]]-[[Clavulanic acid]] 200 mg/kg/day IV divided q6h'''''
|-
|-
|}
|}
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;"
| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Quadruple therapy}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Adults - Mild to Moderate}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Combined Antibiotic Regimen
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Bismuth subsalicylate]] 525 mg orally q6h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefazolin]] 1-2 g IV q8h'''''<br> OR <br> ▸ '''''[[Cefuroxime]] 1.5 g IV q8h'''''<br> OR <br> ▸ '''''[[Ceftriaxone]] 1-2 g IV q12-24h'''''<br> OR <br> ▸ '''''[[Cefotaxime]] 1-2 g IV q6-8h'''''<br> OR <br> ▸ '''''[[Ciprofloxacin]] 400 mg IV q12h'''''<br> OR <br> ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazol]] 250 mg orally q6h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg IV q8-12h''''' <br> OR <br> ▸ '''''[[Metronidazole]] 1.5 g IV q24h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Adults - Severe}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Tetracycline]] 500 mg orally q6h'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Single Antibiotic Regimen
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Imipenem]]-[[Cilastatin]] 500 g IV q6h or 1 g q8h'''''<br> OR <br> ▸ '''''[[Meropenem]] 1 g IV q8h'''''<br> OR <br> ▸ '''''[[Doripenem]] 500 g IV q8h'''''<br> OR <br> ▸ '''''[[Piperacillin]]-[[Tazobactam]] 3.375 g IV q6h<sup>†</sup>'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ranitidine]] 150 mg orally q12h'''''<BR> OR <BR> ▸ '''''[[PPI]] standard dose'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left | <SMALL><sup></sup> For ''[[Pseudomonas aeruginosa]]'' dose may be increased to 3.375 g q4h or 4.5 g q6h .</SMALL>
|-
|-
|}
|}
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="background: #FFFFFF;"
| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Triple therapy}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Adults - Severe}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Combined Antibiotic Regimen
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefepime]] 2 g IV q8-12h'''''<br> OR <br> ▸ '''''[[Ceftazidime]] 2 g IV q8h'''''<br> OR <br> ▸ '''''[[Ciprofloxacin]] 400 g IV q12h'''''<br> OR <br> ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg IV q8-12h'''''<br> OR <br> ▸ '''''[[Metronidazole]] 1.5 g IV q24h'''''
|-
|}
|}
|}
 
===Health Care-Associated===
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
 
{|
| valign=top |
<div class="mw-customtoggle-table07" style="cursor: pointer; border-radius: 5px 5px 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Gram-Negative Bacilli <small>(<20% multidrug resistance)</small> '''
</font>
</div>
 
<div class="mw-customtoggle-table08" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''ESBL-Enterobacteriaceae'''
</font>
</div>
 
<div class="mw-customtoggle-table09" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''P. aeruginosa  <small>(>20% resistant to ceftazidime)</small>'''
</font>
</div>
 
<div class="mw-customtoggle-table10" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Methicillin-resistant S. aureus'''
</font>
</div>
 
<div class="mw-customtoggle-table50" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 310px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Candida spp'''
</font>
</div>
 
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table07" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Gram-Negative Bacilli <small>(<20% multidrug resistance)</small>}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Carbapenem
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 1 g IV q8h'''''<br> OR <br> ▸ '''''[[Imipenem]]/[[Cilastatin]] 500 g IV q6h or 1 g q8h'''''<br> OR <br> ▸ '''''[[Doripenem]] 500 g IV q8h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Cephalosporin-based
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ceftazidime]] 200-300 mg/kg/day IV q12h'''''<br> OR <br> ▸ '''''[[Cefepime]] 200-300 mg/kg/day IV q12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clarithromycin]] 500 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg IV q8-12h'''''<br> OR <br> ▸ '''''[[Metronidazole]] 1.5 g IV q24h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Penicillin-based
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Piperacillin]]-[[Tazobactam]] 3.375 g q4h or 4.5 g q6h '''''
|-
|-
|}
|}
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;"
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table08" style="background: #FFFFFF;"
| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Sequential therapy}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|ESBL-Enterobacteriaceae<sup>†</sup>}}
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''First 5 days'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Carbapenem
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 1 g IV q8h'''''<br> OR <br> ▸ '''''[[Imipenem]]/[[Cilastatin]] 500 g IV q6h or 1 g q8h'''''<br> OR <br> ▸ '''''[[Doripenem]] 500 g IV q8h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Penicillin-based
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Piperacillin]]-[[Tazobactam]] 3.375 g IV q6h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Aminoglycosides
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amikacin]]<sup>¶</sup> 15–20 mg/kg q24 h''''' <br> OR <br>
▸ '''''[[Gentamicin]]<sup>¶</sup> 5-7 mg/kg q24 h''''' <br> OR <br> ▸ '''''[[Tobramycin]]<sup>¶</sup> 5-7 mg/kg q24 h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5"; align=left| <sup>†</sup> <small> ESBL: extended-spectrum β-lactamase <br> <sup>¶</sup> Adjust dosage based on serum concentrations </small>
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table09" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|P. aeruginosa  <small>(>20% resistant to ceftazidime)</small>}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Carbapenem
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 1 g q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 1 g IV q8h'''''<br> OR <br> ▸ '''''[[Imipenem]]/[[Cilastatin]] 500 g IV q6h or 1 g q8h'''''<br> OR <br> ▸ '''''[[Doripenem]] 500 g IV q8h'''''
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Next 5 days'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Penicillin-based
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Piperacillin]]-[[Tazobactam]] 3.375 g IV q6h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Aminoglycosides
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amikacin]]<sup>¶</sup> 15–20 mg/kg q24 h''''' <br> OR <br>
▸ '''''[[Gentamicin]]<sup>¶</sup> 5-7 mg/kg q24 h''''' <br> OR <br> ▸ '''''[[Tobramycin]]<sup>¶</sup> 5-7 mg/kg q24 h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5"; align=left| <sup>¶</sup> <small> Adjust dosage based on serum concentrations </small>
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
 
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table10" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Methicillin-resistant S. aureus}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vancomycin]] 15–20 mg/kg IV q8-12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table50" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Candida spp}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Candida albicans
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clarithromycin]] 500 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Fluconazole]] 50-200 mg PO/IV q24h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Fluconazole-resistant Candida spp
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Tinidazol]] 500 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Caspofungin]] 70 mg IV once, then 50 mg IV q24h''''' <br> OR <br>  ▸ '''''[[Micafungin]] 100 mg IV q24h''''' <br> OR <br>  ▸ '''''[[Anidulafungin]] 200 mg IV once, then 100 mg IV q24h'''''
|-
|-
|}
|}
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="background: #FFFFFF;"
|}
 
==Biliary Infection==
===Community-acquired Acute Cholecystitis===
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
 
{|
| valign=top |
 
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 47px; width: 340px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Acute Cholecystitis'''
</font>
</div>
 
<div class="mw-customtoggle-table11" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 340px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Mild-to-moderate'''
</font>
</div>
 
<div class="mw-customtoggle-table12" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 340px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Severe'''
</font>
</div>
 
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 340px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Special Considerations'''
</font>
</div>
 
<div class="mw-customtoggle-table13" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 340px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Acute Cholangitis after Bilio-enteric Anastomosis'''
</font>
</div>
 
<div class="mw-customtoggle-table14" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 340px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Acute Cholecystitis in Advanced age'''
</font>
</div>
 
<div class="mw-customtoggle-table15" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 340px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Acute Cholecystitis in Immunocompromised'''
</font>
</div>
 
 
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table11" style="background: #FFFFFF;"
| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Sequential therapy}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Mild-to-moderate Acute Cholecystitis}}
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''First 7 days'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefazolin]] 1-2 g IV q8h'''''<br> OR <br> ▸ '''''[[Cefuroxime]] 1.5 g IV q8h'''''<br> OR <br> ▸ '''''[[Ceftriaxone]] 1-2 g IV q12-24h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table12" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Severe Acute Cholecystitis}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 1 g IV q8h'''''<br> OR <br> ▸ '''''[[Imipenem]]/[[Cilastatin]] 500 mg IV q6h or 1 g q8h'''''<br> OR <br> ▸ '''''[[Doripenem]] 500 mg IV q8h'''''<br> OR <br> ▸ '''''[[Piperacillin]]-[[Tazobactam]] 3.375 g IV q6h'''''<br> OR <br> ▸ '''''[[Ciprofloxacin]] 400 mg IV q12h'''''<br> OR <br> ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<br> OR <br> ▸ '''''[[Cefepime]] 2 g IV q8-12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg IV q8-12h'''''<br> OR <br> ▸ '''''[[Metronidazole]] 1.5 g IV q24h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
|}
|-
|}
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table13" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Acute Cholangitis after Bilio-enteric Anastomosis}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 1 g IV q8h'''''<br> OR <br> ▸ '''''[[Imipenem]]/[[Cilastatin]] 500 mg IV q6h or 1 g q8h'''''<br> OR <br> ▸ '''''[[Doripenem]] 500 mg IV q8h'''''<br> OR <br> ▸ '''''[[Piperacillin]]-[[Tazobactam]] 3.375 g IV q6h'''''<br> OR <br> ▸ '''''[[Ciprofloxacin]] 400 mg IV q12h'''''<br> OR <br> ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<br> OR <br> ▸ '''''[[Cefepime]] 2 g IV q8-12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 1 g q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg IV q8-12h'''''<br> OR <br> ▸ '''''[[Metronidazole]] 1.5 g IV q24h'''''
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Next 7 days'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table14" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Acute Cholecystitis in Advanced Age}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[PPI]] standard dose'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 1 g IV q8h'''''<br> OR <br> ▸ '''''[[Imipenem]]/[[Cilastatin]] 500 mg IV q6h or 1 g q8h'''''<br> OR <br> ▸ '''''[[Doripenem]] 500 mg IV q8h'''''<br> OR <br> ▸ '''''[[Piperacillin]]-[[Tazobactam]] 3.375 g IV q6h'''''<br> OR <br> ▸ '''''[[Ciprofloxacin]] 400 mg IV q12h'''''<br> OR <br> ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<br> OR <br> ▸ '''''[[Cefepime]] 2 g IV q8-12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 1 g q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg IV q8-12h'''''<br> OR <br> ▸ '''''[[Metronidazole]] 1.5 g IV q24h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table15" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Acute Cholecystitis in Immunocompromised}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clarithromycin]] 500 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 1 g IV q8h'''''<br> OR <br> ▸ '''''[[Imipenem]]/[[Cilastatin]] 500 mg IV q6h or 1 g q8h'''''<br> OR <br> ▸ '''''[[Doripenem]] 500 mg IV q8h'''''<br> OR <br> ▸ '''''[[Piperacillin]]-[[Tazobactam]] 3.375 g IV q6h'''''<br> OR <br> ▸ '''''[[Ciprofloxacin]] 400 mg IV q12h'''''<br> OR <br> ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<br> OR <br> ▸ '''''[[Cefepime]] 2 g IV q8-12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazol]] 500 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg IV q8-12h'''''<br> OR <br> ▸ '''''[[Metronidazole]] 1.5 g IV q24h'''''
|-
|-
|}
|}
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="background: #FFFFFF;"
|}
| valign=top |
 
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
===Health Care-Associated Biliary Infection===
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Third line treatment}}
 
{| style=" cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Biliary Infection of any severity}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rifabutin]] 150 mg q2h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 1 g IV q8h'''''<br> OR <br> ▸ '''''[[Imipenem]]/[[Cilastatin]] 500 mg IV q6h or 1 g q8h'''''<br> OR <br> ▸ '''''[[Doripenem]] 500 mg IV q8h'''''<br> OR <br> ▸ '''''[[Piperacillin]]-[[Tazobactam]] 3.375 g IV q6h'''''<br> OR <br> ▸ '''''[[Ciprofloxacin]] 400 mg IV q12h'''''<br> OR <br> ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<br> OR <br> ▸ '''''[[Cefepime]] 2 g IV q8-12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 1 g IV q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg IV q8-12h'''''<br> OR <br> ▸ '''''[[Metronidazole]] 1.5 g IV q24h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ciprofloxacin]] 500 mg/kg IV q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vancomycin]] 15–20 mg/kg IV q8-12h'''''
|-
|-
|}
|}
|}
 
|}
==References==
{{Reflist|2}}

Latest revision as of 19:38, 18 June 2014

Overview

Definitions

From a clinical view, intra-abdominal infections can be classified in:[1][2][3]

  • Uncomplicated, in which the infectious process involves only a single organ and there is no anatomical disruption
  • Complicated, in which the infectious process extends beyond the hollow viscus into the peritoneal space and is associated with abscess formation or peritonitits.

Patients with uncomplicated intra-abdominal infections usually do not need antimicrobial therapy besides perioperative prophylaxis and can be managed with surgery alone (i.e. appendicitis).

A health care-associated infection is a new term that describe patients that have a close contact with health systems, they include community-onset infection and hospital-onset infection. The following table describes the two types of health care-associated infection that would guide the therapeutic regimen. [1]

Community-onset infection Hospital-onset infection
Includes patients with 1 or more of the following conditions:
  • The presence of an invasive device at time of admission
  • History of MRSA infection or colonization
  • History of surgery, hospitalization, dialysis, or residence in a long-term care facility in the previous 12 months.
Includes patients with positive culture results obtained >48 h after admission.
Patients might also have 1 of the conditions described in community-onset infection.

Principles of Therapy for Complicated Intra-abdominal Infection

The following table describes the factors that define a high risk infection, due to an increase chance of treatment failure and a more severe infection.[4]

Clinical factors for high risk patients
Delay in the initial intervention (>24 h)
APACHE II score ≥ 15
Advanced age (>70 years)
Comorbidity and degree of organ dysfunction
Low albumin level
Poor nutrition status
Degree of peritoneal involvement or diffuse peritonitis
Inability to achieve adequate debridement or control of drainage
Presence of malignancy
  • All patients should undergo a source control procedure to clear infected foci.[5]
  • Patients should undergo fluid resuscitation to restore cardiovascular homeostasis. For patients with septic shock, follow The Surviving Sepsis Campaign guidelines for managing septic shock.[6]
  • If the diagnosis of intra-abdominal infection is confirmed or is considered highly likely, antibiotics should be initiated immediately.
  • Patients without septic shock should receive the proper [antibiotics]] in the emergency department.[6]
  • Only cultures from the site of infection should be obtained from higher-risk patients, for patients with lower-risk community-acquired infection, cultures are optional.[1]
  • Sensibility testing for Pseudomonas, Proteus, Acinetobacter, Staphylococcus aureus, and Enterobacteriaceae should be done, as this organisms have shown higher resistance rates in recent years.[7]
  • Lower-risk patients with community-acquired intra-abdominal infection which show favorable clinical progress do not require modification of therapy.
  • If microorganisms with high pathogenic potential are found, susceptibility results should be used to determine antibiotic therapy in high-severity community-acquired or health care-associated infection.
  • The recommended duration of therapy is 4-7 days.[8]
  • Completion of the antibiotic course with oral presentations can be considered if the patient evolves favorably, is able to tolerate an oral diet and if his susceptibility studies do not show resistant microorganisms.[9]

Extra-biliary Complicated Intra-abdominal Infection

Community-Acquired

▸ Click on the following categories to expand treatment regimens.

Children

  ▸  Single agent

  ▸  Combination

Adults - Mild to Moderate

  ▸  Single agent

  ▸  Combination

Adults - Severe

  ▸  Single agent

  ▸  Combination

Children
Single Antibiotic Regimen
Ertapenem 15 mg/kg IV q12h (max: 1g/day) (for 3 mo - 12 yrs old)
Ertapenem 1 g IV q24h (for >13 yrs old)
OR
Meropenem 60 mg/kg/day IV divided q8h
OR
Imipenem/Cilastatin 60-100 mg/kg/day IV divided q6h
OR
Ticarcillin-Clavulanate 200-300 mg/kg/day IV divided q4-6h (Ticarcillin component)
OR
Piperacillin-Tazobactam 200-300 mg/kg/day IV divided q6-8h (Piperacillin component)
Children
Combined Antibiotic Regimen 1
Ceftriaxone 50-75 mg/kg/day IV divided q12-24h
OR
Cefotaxime 150-200 mg/kg/day IV divided q6-8h
OR
Cefepime 100 mg/kg/day IV divided q12h
OR
Ceftazidime 150 mg/kg/day IV divided q8h
PLUS
Metronidazole 30-40 mg/kg/day IV divided q8h
Combined Antibiotic Regimen 2
Gentamicin 3-7.5 mg/kg/day IV divided q2-4h
OR
Tobramycin 3-7.5 mg/kg/day IV divided q8-24h
PLUS
Metronidazole 30-40 mg/kg/day IV divided q8h
OR
Clindamycin 20-40 mg/kg/day IV divided q6-8h
WITH OR WITHOUT
Ampicillin 200 mg/kg/day IV divided q6h
Antibiotic serum concentrations and renal function should be monitored
Adults - Mild to Moderate
Single Antibiotic Regimen
Cefoxitin 2 g IV q6h
OR
Ertapenem 1 g IV q24h
OR
Moxifloxacin 400 mg IV q24h
OR
Tigecycline 100 mg initial dose, then 50 mg IV q12h
OR
Ticarcillin-Clavulanic acid 200 mg/kg/day IV divided q6h
Adults - Mild to Moderate
Combined Antibiotic Regimen
Cefazolin 1-2 g IV q8h
OR
Cefuroxime 1.5 g IV q8h
OR
Ceftriaxone 1-2 g IV q12-24h
OR
Cefotaxime 1-2 g IV q6-8h
OR
Ciprofloxacin 400 mg IV q12h
OR
Levofloxacin 750 mg IV q24h
PLUS
Metronidazole 500 mg IV q8-12h
OR
Metronidazole 1.5 g IV q24h
Adults - Severe
Single Antibiotic Regimen
Imipenem-Cilastatin 500 g IV q6h or 1 g q8h
OR
Meropenem 1 g IV q8h
OR
Doripenem 500 g IV q8h
OR
Piperacillin-Tazobactam 3.375 g IV q6h
For Pseudomonas aeruginosa dose may be increased to 3.375 g q4h or 4.5 g q6h .
Adults - Severe
Combined Antibiotic Regimen
Cefepime 2 g IV q8-12h
OR
Ceftazidime 2 g IV q8h
OR
Ciprofloxacin 400 g IV q12h
OR
Levofloxacin 750 mg IV q24h
PLUS
Metronidazole 500 mg IV q8-12h
OR
Metronidazole 1.5 g IV q24h

Health Care-Associated

▸ Click on the following categories to expand treatment regimens.

  ▸  Gram-Negative Bacilli (<20% multidrug resistance)

  ▸  ESBL-Enterobacteriaceae

  ▸  P. aeruginosa (>20% resistant to ceftazidime)

  ▸  Methicillin-resistant S. aureus

  ▸  Candida spp

Gram-Negative Bacilli (<20% multidrug resistance)
Carbapenem
Meropenem 1 g IV q8h
OR
Imipenem/Cilastatin 500 g IV q6h or 1 g q8h
OR
Doripenem 500 g IV q8h
Cephalosporin-based
Ceftazidime 200-300 mg/kg/day IV q12h
OR
Cefepime 200-300 mg/kg/day IV q12h
PLUS
Metronidazole 500 mg IV q8-12h
OR
Metronidazole 1.5 g IV q24h
Penicillin-based
Piperacillin-Tazobactam 3.375 g q4h or 4.5 g q6h
ESBL-Enterobacteriaceae
Carbapenem
Meropenem 1 g IV q8h
OR
Imipenem/Cilastatin 500 g IV q6h or 1 g q8h
OR
Doripenem 500 g IV q8h
Penicillin-based
Piperacillin-Tazobactam 3.375 g IV q6h
Aminoglycosides
Amikacin 15–20 mg/kg q24 h
OR

Gentamicin 5-7 mg/kg q24 h
OR
Tobramycin 5-7 mg/kg q24 h

ESBL: extended-spectrum β-lactamase
Adjust dosage based on serum concentrations
P. aeruginosa (>20% resistant to ceftazidime)
Carbapenem
Meropenem 1 g IV q8h
OR
Imipenem/Cilastatin 500 g IV q6h or 1 g q8h
OR
Doripenem 500 g IV q8h
Penicillin-based
Piperacillin-Tazobactam 3.375 g IV q6h
Aminoglycosides
Amikacin 15–20 mg/kg q24 h
OR

Gentamicin 5-7 mg/kg q24 h
OR
Tobramycin 5-7 mg/kg q24 h

Adjust dosage based on serum concentrations
Methicillin-resistant S. aureus
Vancomycin 15–20 mg/kg IV q8-12h
Candida spp
Candida albicans
Fluconazole 50-200 mg PO/IV q24h
Fluconazole-resistant Candida spp
Caspofungin 70 mg IV once, then 50 mg IV q24h
OR
Micafungin 100 mg IV q24h
OR
Anidulafungin 200 mg IV once, then 100 mg IV q24h

Biliary Infection

Community-acquired Acute Cholecystitis

▸ Click on the following categories to expand treatment regimens.

Acute Cholecystitis

  ▸  Mild-to-moderate

  ▸  Severe

Special Considerations

  ▸  Acute Cholangitis after Bilio-enteric Anastomosis

  ▸  Acute Cholecystitis in Advanced age

  ▸  Acute Cholecystitis in Immunocompromised


Mild-to-moderate Acute Cholecystitis
Cefazolin 1-2 g IV q8h
OR
Cefuroxime 1.5 g IV q8h
OR
Ceftriaxone 1-2 g IV q12-24h
Severe Acute Cholecystitis
Meropenem 1 g IV q8h
OR
Imipenem/Cilastatin 500 mg IV q6h or 1 g q8h
OR
Doripenem 500 mg IV q8h
OR
Piperacillin-Tazobactam 3.375 g IV q6h
OR
Ciprofloxacin 400 mg IV q12h
OR
Levofloxacin 750 mg IV q24h
OR
Cefepime 2 g IV q8-12h
PLUS
Metronidazole 500 mg IV q8-12h
OR
Metronidazole 1.5 g IV q24h
Acute Cholangitis after Bilio-enteric Anastomosis
Meropenem 1 g IV q8h
OR
Imipenem/Cilastatin 500 mg IV q6h or 1 g q8h
OR
Doripenem 500 mg IV q8h
OR
Piperacillin-Tazobactam 3.375 g IV q6h
OR
Ciprofloxacin 400 mg IV q12h
OR
Levofloxacin 750 mg IV q24h
OR
Cefepime 2 g IV q8-12h
PLUS
Metronidazole 500 mg IV q8-12h
OR
Metronidazole 1.5 g IV q24h
Acute Cholecystitis in Advanced Age
Meropenem 1 g IV q8h
OR
Imipenem/Cilastatin 500 mg IV q6h or 1 g q8h
OR
Doripenem 500 mg IV q8h
OR
Piperacillin-Tazobactam 3.375 g IV q6h
OR
Ciprofloxacin 400 mg IV q12h
OR
Levofloxacin 750 mg IV q24h
OR
Cefepime 2 g IV q8-12h
PLUS
Metronidazole 500 mg IV q8-12h
OR
Metronidazole 1.5 g IV q24h
Acute Cholecystitis in Immunocompromised
Meropenem 1 g IV q8h
OR
Imipenem/Cilastatin 500 mg IV q6h or 1 g q8h
OR
Doripenem 500 mg IV q8h
OR
Piperacillin-Tazobactam 3.375 g IV q6h
OR
Ciprofloxacin 400 mg IV q12h
OR
Levofloxacin 750 mg IV q24h
OR
Cefepime 2 g IV q8-12h
PLUS
Metronidazole 500 mg IV q8-12h
OR
Metronidazole 1.5 g IV q24h

Health Care-Associated Biliary Infection

Biliary Infection of any severity
Meropenem 1 g IV q8h
OR
Imipenem/Cilastatin 500 mg IV q6h or 1 g q8h
OR
Doripenem 500 mg IV q8h
OR
Piperacillin-Tazobactam 3.375 g IV q6h
OR
Ciprofloxacin 400 mg IV q12h
OR
Levofloxacin 750 mg IV q24h
OR
Cefepime 2 g IV q8-12h
PLUS
Metronidazole 500 mg IV q8-12h
OR
Metronidazole 1.5 g IV q24h
PLUS
Vancomycin 15–20 mg/kg IV q8-12h

References

  1. 1.0 1.1 1.2 Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ; et al. (2010). "Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America". Clin Infect Dis. 50 (2): 133–64. doi:10.1086/649554. PMID 20034345.
  2. Mazuski JE, Solomkin JS (2009). "Intra-abdominal infections". Surg Clin North Am. 89 (2): 421–37, ix. doi:10.1016/j.suc.2008.12.001. PMID 19281892.
  3. Blot S, De Waele JJ (2005). "Critical issues in the clinical management of complicated intra-abdominal infections". Drugs. 65 (12): 1611–20. PMID 16060697.
  4. Koperna T, Schulz F (1996). "Prognosis and treatment of peritonitis. Do we need new scoring systems?". Arch Surg. 131 (2): 180–6. PMID 8611076.
  5. Marshall JC, Maier RV, Jimenez M, Dellinger EP (2004). "Source control in the management of severe sepsis and septic shock: an evidence-based review". Crit Care Med. 32 (11 Suppl): S513–26. PMID 15542959.
  6. 6.0 6.1 Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM; et al. (2013). "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012". Intensive Care Med. 39 (2): 165–228. doi:10.1007/s00134-012-2769-8. PMID 23361625.
  7. Hawser SP, Bouchillon SK, Hoban DJ, Badal RE (2009). "In vitro susceptibilities of aerobic and facultative anaerobic Gram-negative bacilli from patients with intra-abdominal infections worldwide from 2005-2007: results from the SMART study". Int J Antimicrob Agents. 34 (6): 585–8. doi:10.1016/j.ijantimicag.2009.07.013. PMID 19748234.
  8. Solomkin JS, Mazuski JE, Baron EJ, Sawyer RG, Nathens AB, DiPiro JT; et al. (2003). "Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections". Clin Infect Dis. 37 (8): 997–1005. doi:10.1086/378702. PMID 14523762.
  9. Solomkin JS, Dellinger EP, Bohnen JM, Rostein OD (1998). "The role of oral antimicrobials for the management of intra-abdominal infections". New Horiz. 6 (2 Suppl): S46–52. PMID 9654311.