Initial Empiric Treatment of biliary Complicated Intra-abdominal Infection

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Initial Empiric Treatment of biliary Complicated Intra-abdominal Infection
Definition Signs/ Symptoms Management
Antibiotic Comment
Community-acquired acute cholecystitis of mild-to-moderate severity Rapid-onset abdominal pain and symptoms of gastrointestinal dysfunction (loss of appetite, nausea, vomiting, bloating, and/ or obstipation), with or without signs of inflammation (pain, tenderness, fever, tachycardia, and/or tachypnea)

Single agents: Select one of the following antibiotics

  • Cefazolin 1–2 g IV every 8 hours
  • Cefuroxime 1.5 g IV every 8 hours
  • Ceftriaxone 1–2 g IV every 24 hours
Community-acquired acute cholecystitis of severe physiologic disturbance, advanced age, or immunocompromised state OR Acute cholangitis following bilio-enteric anastomosis of any severity

Single agent: Select one of the following antibiotics

  • Piperacillin-tazobactam 4.5 g IV every 6 hours
  • Imipenem-cilastatin 500 mg IV every 6 hours or 1 g every 8 hours
  • Meropenem 1 g IV every 8 hours

OR

Combination: Select one of the following antibiotics

  • Levofloxacin 750 mg IV every 24 hours
  • Ciprofloxacin 400 mg IV every 12 hours
  • Cefepime 2 g IV every 8–12 hours

PLUS

  • Metronidazole 500 mg IV every 8–12 hours
Health care–associated biliary infection of any severity

Single agent: Select one of the following antibiotics

  • Piperacillin-tazobactam 4.5 g IV every 6 hours
  • Imipenem-cilastatin 500 mg IV every 6 hours or 1 g every 8 hours
  • Meropenem 1 g IV every 8 hours

OR

Combination: Select one of the following antibiotics

  • Levofloxacin 750 mg IV every 24 hours
  • Ciprofloxacin 400 mg IV every 12 hours
  • Cefepime 2 g IV every 8–12 hours

PLUS

  • Metronidazole 500 mg IV every 8–12 hours

PLUS

  • Vancomycin 15–20 mg/kg IV every 8–12 hours

Added to each regimen (single agent AND combination)

 We add ampicillin or vancomycin to cephalosporin-based regimen to provide enterococcal coverage , particularly in those with *Postoperative infection, *Prior use of antibiotics that select for enterococcus , *Immunocompromising condition, *Valvular heart disease , or *Prosthetic intravascular materials.
Duration: 4–7 days, unless it is difficult to achieve adequate source control.
References:

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