Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery

Methods

• Statement 1In patients with cIAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects requiring careful clinical assessment: (1) The anatomic extent of infection; (2) the presumed pathogens and risk factors for antimicrobial resistance (AMR); (3) the origin of the infection; (4) the patient’s clinical condition; and (5) the host’s immune status. Assessment should be continuous to optimize managementVery low-quality evidence, Strong recommendation
• Statement 2IAI is the setting where source control is most impactful. Achievement of source control is the single most important determinant of patients’ outcomes from cIAI, allowing for short-course antibiotic therapy that reduces antibiotic selection pressure. Source control should be undertaken promptly to remove devitalized tissue and infected fluid and prevent ongoing contaminationLow-quality evidence, Strong recommendation
• Statement 3The origin of the infection should be always investigated for treatment planning. In physiologically deranged patients (i.e., septic shock), early exploration may be performed even if the source of infection is not definedVery low-quality evidence, Strong recommendation
• Statement 4In the event of uIAIs, such as acute appendicitis or acute cholecystitis, if the focus of infection is controlled by appropriate surgical management, post-operative antibiotic therapy is not necessary. In the event of cIAIs, treatment generally involves source control and antibiotic therapy. Selected patients with perforated diverticulitis (including those with an abscess < 4 cm in diameter), a peri-appendiceal mass or phlegmon, or a perforated gastroduodenal ulcer (i.e., no sepsis, peritonitis, or extravasation by water-soluble contrast gastroduodenography) can be managed without definitive source control if responding satisfactorily to antibiotic therapy and other supportive measuresLow-quality evidence, Strong recommendation
• Statement 5For patients with uncomplicated acute appendicitis, appendectomy is the standard treatment. If source control is adequate, post-operative antibiotic therapy is not necessary. Treatment by antibiotics alone may be used in selected non-pregnant patients with uncomplicated acute appendicitis and no appendicolith. However, non-operative management (NOM) is less effective than surgery in the long term due to a high recurrence rateHigh-quality evidence, Strong recommendation
• Statement 6In patients with uncomplicated acute cholecystitis, early laparoscopic cholecystectomy is the standard treatment. If source control is adequate, post-operative antibiotic therapy is not necessary. If early cholecystectomy is not performed, interval cholecystectomy should be planned between 6 and 12 weeks after the episode of acute cholecystitisModerate-quality evidence, Strong recommendation
• Statement 7In immunocompetent patients with uncomplicated mild acute diverticulitis, antibiotic therapy may be omittedModerate-quality evidence, Weak recommendation
• Statement 8In patients with cIAIs undergoing adequate source control, 4 days of fixed-duration antibiotic therapy is sufficient. In the setting of complicated acute appendicitis, the duration of antibiotic therapy may be shortened further in selected patientsHigh-quality evidence, Strong recommendation
• Statement 9Ongoing signs of abdominal infection or systemic illness after 7 days of antibiotic therapy warrant cessation of therapy and a diagnostic investigation rather than prolongation or modification of antibiotic therapyLow-quality evidence, Strong recommendation
• Statement 10Biomarkers such as procalcitonin can guide antibiotic duration in patients with signs of ongoing infectionLow-quality evidence, Weak recommendation
• Statement 11Narrow-spectrum antibiotic regimens having activity against typical gram-negativeEnterobacterales, gram-positive cocci, and obligate anaerobes should be used to treat patients with community-acquired cIAIs. In this setting, broad-spectrum or additional agents to provide anti-pseudomonal or anti-enterococcal coverage or antifungal therapy should not be used routinelyLow-quality evidence, Strong recommendation
• Statement 12For patients with hospital-acquired IAIs, agent(s) with broad-spectrum activity are preferredModerate-quality evidence, Strong recommendation
• Statement 13Patients who have received recent broad-spectrum antimicrobial therapy, had prolonged hospitalizations, underwent multiple invasive interventions, or are known to have been colonized or infected with a resistant gram-negative organism should be considered at risk for infection from a resistant gram-negative pathogenModerate-quality evidence, Strong recommendation
• Statement 14Antibiotic regimens with activity against multidrug-resistant (MDR) bacteria should be used for selected patients with IAIs who are strongly suspected or proved to be harbouring a resistant pathogenModerate-quality evidence, Strong recommendation
• Statement 15In patients with cIAIs at risk of resistant pathogens, culture and susceptibility testing of peritoneal fluid at the site of infection should always be obtained. If resources are available, cultures should be obtained from all patients with cIAIs to analyze epidemiologic data that can be used to guide empiric antibiotic therapyLow-quality evidence, Weak recommendation
• Statement 16For adults with sepsis (multiple organ dysfunction syndrome) or shock due to hospital-acquired cIAIs, empiric antifungal therapy for Candida spp. should be considered, especially those with recent abdominal surgery or gastrointestinal anastomotic leak. Empiric antifungal therapy may be considered for high-risk patients with community-acquired infectionsLow-quality evidence, Strong recommendation
• Statement 17Sepsis and septic shock are time-dependent emergencies and resuscitation should start immediatelyHigh-quality evidence, Strong recommendation
• Statement 18Fluid administration should be individualized for every patient, based on the evaluation of a need for fluid and on any premorbid conditionsLow-quality evidence, strong recommendation
• Statement 19Vasopressor agents should be administered to restore organ perfusion as soon as possible if blood pressure is not restored after initial fluid resuscitationLow-quality evidence, Strong recommendation
• Statement 20Fluid overload should be avoided in adults with sepsis or septic shock of abdominal originVery low-quality evidence, Strong recommendation
• Statement 21Specific adjunctive therapy can be considered in selected patients, evaluating the potential benefit and possible harm.Low quality evidence, Weak recommendation
• Statement 22For adults with septic shock, early and properly administered empiric antibiotic therapy has a significant impact on outcomeModerate-quality evidence, Strong recommendation
• Statement 23In adults with sepsis or septic shock, appropriate dosing and administration of antibiotics should include a loading dose and extended or continuous infusion for beta-lactam agents.Low-quality evidence, Strong recommendation
• Statement 24After rapid patient stabilization, adults with sepsis and septic shock should undergo a source control procedure within 6 h. Time from admission to initiation of surgery for source control is a crucial determinant of survival in from sepsis and septic shockLow-quality evidence, Strong recommendation
• Statement 25For adults with abdominal sepsis or septic shock, on-demand re-laparotomy (as opposed to scheduled reoperation) should be the first-choice approach to re-operationModerate quality evidence, Strong recommendation
• Statement 26Damage control surgery may be an option in selected physiologically deranged patients with sepsis of abdominal originVery low-quality evidence, Strong recommendation
• Statement 27Based on the complexity of IAI (variable clinical presentations depending on the original site of infection, the causative organism, the pattern of acute organ dysfunction, and the underlying health status of the patient), an individualized, carefully designed approach to source control is the best pathway to followVery low-quality evidence, Strong recommendation
• Statement 28Immunocompromised patients with IAIs are at increased risk of morbidity and mortality and may fail standard NOM when otherwise indicated.Low-quality evidence, Strong recommendation