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IDSA updates guidelines for management of intra-abdominal infection
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Updated recommendations for non-operative management of acute appendicitis are among the key changes to the guidelines for the diagnosis and management of complicated intra-abdominal infection in adults and children, which were published recently by the Infectious Diseases Society of America.
Joseph S. Solomkin, MD, of the department of surgery at the University of Cincinnati College of Medicine, was involved in the publication of the guidelines.
“We wanted to include and really focus on the appendicitis pathway,” he told Infectious Diseases in Children. “The timing was dictated by the strong sense that particularly the operative and radiographic percutaneous intervention material had really become so widely applied and widely used that it needed to be separately discussed. We wanted to broaden the guidelines in terms of the surgical element. Basically, we were leaning toward more non-operative management of conditions, primarily the current interest in non-operative management of acute appendicitis.”
Solomkin said that the researchers wanted to highlight the role of percutaneous drainage and non-operative management procedures. There was a focus on the use of antibiotic therapy as definitive primary therapy in place of operative intervention.
However, despite this, Solomkin said that reducing antibiotic usage also factored into the development of the guidelines.
Antimicrobial stewardship
“We tried hard to keep the attention on antimicrobial stewardship,” he said. “A key point with antimicrobial therapy was to shorten the duration of treatment wherever possible.”
Solomkin noted that antibiotic prophylaxis for necrotizing pancreatitis is no longer recommended. “Several well-done, high-quality studies have demonstrated that there is no benefit of antimicrobial prophylaxis for this infection. Apart from the fact that the prophylaxis is ineffective, it is a gross violation of antibiotic stewardship to give people six weeks of carbapenems,” he said.
The other key change highlighted by Solomkin was the addition of a pediatric section to the guidelines. “We added this section primarily because of appendicitis,” he said. “We wanted to make sure the recommendation for pathways for the treatment of acute appendicitis in children was consistent.”
Other changes highlighted by Solomkin included the shift toward carbapenems as treatment for health care associated gram-negative infections and the shift from Unasyn (ampicillin sodium, sulbactam sodium; Pfizer) as first-line treatment of mild to moderate infections. He also noted the shift from clindamycin as a first-line agent for mild to moderate infections.
In keeping with the theme of antimicrobial stewardship, the reduction in Unasyn usage is to prevent resistance among Escherichia coli strains, and the reduction in clindamycin usage is to prevent resistance among bacteroides sources.
The guidelines were prompted by updated data on studies conducted from 2003 to 2008. Solomkin also said that the desire to promote development of local guidelines factored into the new iteration.
Solomkin JS. Clin Infect Dis. 2010;50:133-164.