ABDOMINAL INFECTIONS AND PUERPURAL SEPSIS

1. ABDOMINAL INFECTIONS AND PUERPURAL SEPSIS Samuel Mwaniki

2. OBJECTIVES • Describe pathogenesis & clinical characteristics of intra-abdominal infections • Identify most likely etiologic organism(s) • Review appropriate drug therapy

3. INTRA-ABDOMINAL INFECTIONS Infections contained within the peritoneum or retroperitoneal space. Peritoneal cavity contains: • Stomach • Jejunum, Ileum • Appendix • Large intestine (colon) • Liver, gallbladder and spleen Retroperitoneal space: • Duodenum • Pancreas • Kidneys

4. Intra-abdominal Infections • Appendicitis • Peritonitis • Intra-abdominal Abscess • Diverticulitis • Antibiotic-Associated Diarrhea - Clostridium difficile • Food Poisoning/Traveler’s Diarrhea – E. Coli • PUD - Helicobacter pylori • Pelvic Inflammatory Disease

5. GI Microflora Stomach: • H. Pylori, Lactobacilli Upper Intestine: • Streptococci, Enterococci, Staphylococci, E. Coli, Klebsiella, Bacteroides Ileum: • Streptococci, Staphylococci, Escherichia coli, Klebsiella, Enterobacter, Bacteroides, Clostridium Colon: • Bacteroides, Peptostreptococci, Clostridium, Bifidobacterium, Escherichia coli, Klebsiella, Enterobacter, Enterococci, Staphylococci

6. Peritonitis Inflammation of the serous lining of the peritoneal cavity due to: • Microorganisms • Chemicals • Irradiation • Foreign body injury

7. Primary (Spontaneous Bacterial Peritonitis) • No focus of disease is evident • Arises without a breach in the peritoneal cavity or GIT • Bacteria transported from blood stream to peritoneal cavity (Cirrhosis, CAPD) • Usually monomicrobial

8. Secondary • Acute perforation of the GI tract (diverticulitis - ), appendix (appendicitis), gallbladder, tumor perforations) • Community acquired or nosocomial • Usually polymicrobial • Post-operative peritonitis • Post-traumatic peritonitis

9. Tertiary • Peritonitis in a critically ill patient which persists or recurs at least 48 h after apparently adequate management of primary or secondary peritonitis

10. Clinical Symptoms • Abdominal pain • Anorexia (N/V) • Fever (38-40 ºC) • Abdominal distention and tenderness • Hypoactive or faint bowl sounds • Leukocytosis

11. Normally: • 20 to 50 mLtransudate • Peritoneal membrane measures approx. 1.7 metres square • WBC < 300 cells/mm3 • Protein: <3 g/dL Bacterial peritonitis: • 300 to 500mL inflow/hr resulting in hypovolemia. • WBC > 300 cells/mm3 • Gram stain + for bacteria

12. Microbiology • Blood cultures often –ve • Peritoneal fluid used (parecentesis) • Health care associated intra-abdominal infection usually due to nosocomial organisms particular to the site of the operation and specific hospital and unit

13. Community acquired infections • infections derived from stomach, duodenum, biliary system and proximal small bowel: • Gram positive and Gram negative aerobic and facultative bacteria • distal small bowel: • Gram negative facultative and aerobic bacteria • Anaerobes • large bowel: • Facultative and obligate anaerobic bacteria • Streptococi and enterococci commonly present

14. Aerobes: • GN Bacilli: E. Coli, Klebsiella,Enterobacter, Proteus mirabilis, Pseudomonas aeruginosa • GP Cocci: Enterococcus spp e.g. E. faecalis, Streptococcus, S.aureus, Coagulase –ve Staphylococcus

15. Anaerobes: • GN Bacilli : B.fragilis, Prevotella, Pophyromonas • GP Cocci: Clostridium spp, Peptostreptococcus. Fungi: • C. albicans

16. Appendicitis • Highest incidence 10-19y/o • Male > female • Pathophysiology: Relationship to onset of sx 0-24h after sx onset: obstruction within appendix , inflammation & occlusion of vascular & lymphatic flow, bacterial overgrowth then necrosis. >48h after sx onset: perforation, abscess/peritonitis Early sx: dull, non-localized pain, indigestion,bowelirregularity, flatulence Later sx: pain/tenderness more localized, N/V, Fever >39 degrees celcius, leukocytes >15000: perforation likely

17. Management Acute, non-perforated appendicitis • cefazolin + metronidazole Perforated appendicitis • Cover enteric gram – rods and anaerobes (2nd/3rd generation ceph or FQ) + metronidazole, Cefoxitin, piperacillin/tazobactam, ampicillin/sulbactam, imipenem • Antibiotics are started before surgery, continued for 7- 10 days • Switch to PO based on patient status

18. Intra – abdominal Abscess • Abscess: purulent collection of fluid, necrotic debris, bacteria, inflammatory cells that is walled off/encapsulated by adjacent healthy cells in an attempt to keep pus from infecting neighboring structures. • Encapsulation can prevent immune cells/abx from attacking contained bacteria, low O2 in capsule, anaerobes thrive here! • A Result of chronic inflammation, develop over days-yrs • Located within peritoneal cavity or visceral organs • May range from a few milliliters to a liter in volume

19. Ruptured abscess • Spread of bacteria + toxins into peritoneum - peritonitis • Spread of bacteria + toxins into systemic circulation – sepsis, multi-organ failure, death Presentation: • Nonspecific low grade or spiking fever, abdominal pain/discomfort +/- distension Labs: • Leukocytosis, +/- positive blood cultures, +/-hyperglycemia • Ultrasound, GI contrast study, or CT scan may be used for evaluation

20. Microbiology • Usually mixed infection: aerobes & anaerobes within the same abscess • E. coli • Klebsiella • Enterococci • B. fragilis • Clostridium

21. Management Combination of modalities: • Surgical: Prompt drainage of abscess (secondary peritonitis) and/or debridement, Resection of perforated colon, small intestine, ulcers, Repair of trauma. • Support of Vital functions: Blood pressure/fluid replacement, Monitor heart rate, Monitor urine out put (0.5 ml/kg/hr) • Appropriate antimicrobial therapy

22. Empiric Antibiotic Therapy MUST include aerobic/anaerobic coverage Agents with Aerobic and Anaerobic activity: • Ampicillin/sulbactam - (enterococci) • Piperacillin/tazobactam - (enterococci) • Imipenem/cilistatin • Meropenem • Ertapenem • Aminoglycoside+ clindamycin or metronidazole • Tigecycline • Moxifloxacin - (active against 83% of Bacteroides strains)+ metronidazole

23. Antibiotic Associated Diarrhoea • Antibiotic therapy (broad spectrum agents: clindamycin, ampicillin, 3rd generation cephalosporins are most common) • Disruption of normal colonic flora • C. difficile colonization (gram +, spore forming anaerobe) • Release of toxins A (enterotoxin), B (cytotoxin), & binary toxin • CDT (associated w/ recent outbreaks) • Damage to colonic mucosa (pseudomembranous plaques),inflammation, intestinal fluid secretion

24. Treatment FIRST LINE: • Metronidazole(Treatment of Choice) • 250mg PO QID or 500mg PO/IV TID x 10-14 days ALTERNATIVE: (if pregnant, not responding to metronidazole or recurrences) • Vancomycin • 125mg PO QID x 10-14 days +/- rifampin600mg PO BID Always stop the drug responsible for causing the infection as soon as possible!

25. PUERPURAL SEPSIS Definition of Puerpurum • The time from the delivery of the placenta through the first few weeks after the delivery. • 6 weeks in duration. • By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the non pregnant state.

26. Puerperal Infection Any bacterial infection of the genital tract after delivery. Incidence: 6%. The most important cause of maternal death. Puerperal Morbidity Temperature 38.0℃ or higher, the temperature to occur on any 2 of the first 10days postpartum, exclusive of the first 24 hours, and to be taken by mouth by a standard technique at least four times daily.

27. Risk factors • Anaemia • Hemorrhage • Episiotomy and CS • Placenta retention • Hospital contamination

28. Common pathogens • Aerobes • Group A, B, and D streptococci • Gram-negative bacteria: Escherichia coli, Klebsiella • Staphylococcus aureus

29. Anaerobes • Peptostreptococcus species • Bacteroides fragilis group • Clostridium species • Other • Chlamydia trachomatis • Mycoplasma species

30. Manifestation • Acute vulvitis, vaginitis,cervicitis and endometritis • Uterine infection • Adnexal infections • Septic pelvic thrombophlebitis • Sapremia (blood poisoning resulting from absorption of putrefaction matter from the uterus)

31. MERCI BEACOUP, MADAME MADEMOISELLE ET MESSRS!