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Disease / Etiology
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Preferred
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Alternative
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Comments
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Biliary tract infection:
Cholecytits, cholangitis, biliary sepsis or common duct obstruction
Microorganisms:
Gram negative aeroebs:
E coli
Klebsiella sp,
Enterococcus faecalis (less common, treatment for enterococcus is rarely indicated in mild and moderate disease)
Anaerobe rare unless there is biliary obstruction: Bacteroides (rarely- perforation, serious illness and bowel manipulation)
Yeast (rarely)
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Co-amoxiclav 1.2 gm IV q8H
In septic shock or needing ICU management or patient with risk of Pseudomonas:
Piperacillin / Tazobactam 4.5 gm IV q6H
|
Cefoperazone 1 - 2 gm IV q12H
OR
Cefuroxime 1.5 gm IV q8H
+
Metronidazole 500 mg IV q8H
±
Gentamicin 3 - 5 mg/kg IV q24H if risk of Pseudomonas present |
Duration: 4 - 7 days (4 days if there is good source control).
Clinical improvement:
Co-amoxiclav 625 mg PO q8H
OR
Cefuroxime 500 mg PO q12H
+
Metronidazole 400 mg PO q8H
To consider laparocsopic cystectomy during presentation.
Blood cultures should be taken BEFORE antibiotics.
Use susceptible testing to guide ongoing therapy.
Biliary drainage should be performed for moderate to severe cholangitis.
Empirical agents should be changed according to bile C&S.
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Infectious Diarrhea
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Acute mild to moderate diarrhea
Virus: norovirus (usually)
Bacteria (Salmonella)
Parasite (rarely)
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To replace fluids.
No antibiotics required. |
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Mild: ≤ 3 unformed stools, minimal symptoms
Moderate: ≥ 3 unformed stools and/or symptomatic
Severe: fever (> 38.5oC), ≥ 6 unformed stool. Severe diarrhea in the elderly, fecal leucocytes ± bloody stools.
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Acute severe diarrhoea
Campylobacter
Yersinia
Salmonella
Aeromonas
Plesiomonas spshigella
shigelloides
C difficile |
Ciprofloxacin 500 mg - 750 mg PO q12H for 3 - 5 days.
If C diff suspected, to add Metronidazole 400 mg - 800 mg PO q8H for 10 - 14 days
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Co-trimoxazole (480 mg) 2 tablets PO q12H for 3 - 5 days
OR
Azithromycin 500 mg PO q24H for 3 days
Alternative,
Vancomycin 125 mg - 500 mg PO q6H for 14 days
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Hepatic Abscess
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Pyogenic abscess:
Enterobacteriaceae
Strep anginosus/milleri (occasionally)
Enterococci
Bacteroides
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Co-amoxiclav 1.2 gm IV q8H
If septic shock:
Piperacillin / Tazobactam 4.5 gm IV q6H |
Cefoperazone 2 gm IV q12H
OR
Ceftriaxone 2 gm IV q24H
+
Metronidazole 500 mg IV q8H
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Duration: 4 - 6 weeks.
Modify antibiotics according to culture.
Convert to oral once clinically improved.
If no culture available, oral Co-amoxiclav can be used.
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Amoebic abscess:
Entamoeba histolytica |
Metronidazole 500 mg IV q8H
Switch to Metronidazole 400 mg PO q8H for 10 days when clinical improvement occurs.
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Tinidazole 2 gm PO q24H for 3 - 5 days |
Tinidazole not available in UMMC. |
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Acute Pancreatitis
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Mild to moderate pancreatitis including alcoholic pancreatitis |
Antibiotics not required |
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Severe non necrotizing pancreatitis |
Antibiotics not required |
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Perform an image guided percutaneous aspiration before antibiotics.
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Severe non infected necrotizing pancreatitis
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Antibiotics not required |
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Prophylaxis antibiotics to prevent pancreatic infection are no longer recommended because of lack of benefit and possibly of harm.
Surgical debridement is the treatment of choice.
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Severe infected necrotizing pancreatitis: infected pseudo cyst, pancreatic abscess
Enterobacteriaceae
Enterococci
Staph aureus
Streptococcus
Staph Epidemidis
Anaerobes
Candida spp (Rarely)
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Imipenem* 500 mg IV q6H |
Cefoperazone 1 - 2 gm IV q12H
+
Metronidazole 500 mg IV q8H
OR
Piperacillin / Tazobactam 4.5 gm IV q6H |
* Deescalate antibiotic once culture and sensitivity result is available. |
Prophylaxis antibiotics if > 30% of pancreas necrotic on CT scan
(CONTROVERSIAL)
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Imipenem 500 mg IV q6H
OR
Meropenem 1 gm IV q8H
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Duration: if cultures are negative, stop antibiotics by Day 3.
Perform an image guided percutaneous aspiration before antibiotics.
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Diverticular Disease
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Diverticulitis, appendicitis, Peri-diverticular abscess, Peri-appendiceal abscess, Peritonitis due to Perforated viscus, Perirectal abscess:
Enterobacteriaceae
Enterococci (in perforation of large bowel)
Anaerobes
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Mild to moderate:
Co-amoxiclav 1.2 gm IV q8H
Severe or if patient is at risk of Pseudomonas infection:
Piperacillin / Tazobactam 4.5 gm IV q6H
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Mild to moderate:
Cefuroxime 1.5 gm IV q8H
+
Metronidazole 500 mg IV q8H
±
Ampicillin 2 gm IV q6H (if involved perforation of large bowel)
Severe or if patient is at risk of Pseudomonas infection:
Ceftazidime 2 gm IV q8H
+
Metronidazole 500 mg IV q8H
±
Ampicillin 2 gm IV q6H (if involved perforation of large bowel)
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Duration: 5 - 10 days.
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Spontaneous Bacterial Peritonitis (SBP)‡
Entereobacteriaceae (63%)
S. pneumoniae (15%)
Enterococci (6-10%)
Anaerobes (uncommon)
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Co-amoxiclav 1.2 gm IV q8H
If patient is at risk of Pseudomonas infection: Piperacillin / Tazobactam 4.5 gm IV q6H
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Ceftriaxone 2 gm IV q24H
+
Metronidazole 500 mg IV q8H |
Duration: 5 - 7 days
* Add Ampicillin 1 - 2 gm IV q6H if on Co-trimoxazole or Norfloxacin prophylaxis because in these cases, Streptococcus and Enterococci are more common |
Esophageal Gastric Infection
Esophageal Perforation
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Piperacillin / Tazobactam 4.5 gm IV q6H
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Cefoperazone 1 - 2 gm IV q12H
+
Metronidazole 500 mg IV q8H
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When clinically improved, change to:
Co-trimoxazole (480 mg) 2 tablets PO q12H
+
Metronidazole 400 mg PO q8H
OR
Co-amoxiclav 625 mg PO q8H
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Perforated Gastric / Duodenal Ulcers |
Co-amoxiclav 1.2 gm IV q8H
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