3.15 Surgical related infections [New]

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Hepato-Pancreato-billiary

Acute Pancreatitis

 
Mild to moderate pancreatitis including alcoholic pancreatitis
 
Antibiotics not required

 




 
Severe non necrotizing pancreatitis

Antibiotics not required


 
Perform an image guided percutaneous aspiration before antibiotics.


Severe non infected necrotizing pancreatitis
 
Antibiotics not required

 


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 where clinically indicated.


Severe infected necrotizing pancreatitis: infected pseudo cyst, pancreatic abscess

 

Piperacillin/ Tazobactam 4.5gm IV q6H

OR

Meropenem 1gm IV q8H **

 

Cefepime 2gm IV q8H

+

Metronidazole 500mg IV q8H


* To obtain cultures (preferable tissue culture), streamline antibiotic once culture and sensitivity result is available.

** only if is hospital acquired

Duration depending on the organ involved and type of extra-pancreatic infection or collection which may require drainage.

If culture is negative and no source of infection identified, will need to stop the antibiotics.


Biliary tract infection

 

Cholecystitis

Cholangitis or biliary sepsis secondary to common duct obstruction

Gallbladder empyema

 

 
Co-amoxiclav 1.2 gm IV q8H 
for 4-7 days

OR, if severe



Piperacillin / Tazobactam 4.5 gm IV q6H 

 
Cefoperazone 1 - 2 gm IV q12H for 4-7 days


 
Appropriate source control to drain any infected foci (e.g. gallbladder empyema) is recommended

 

Gastrointestinal

Diverticulitis


Patient is from the community with no prior antibiotic use for this episode

 

 

Patient is diagnosed during inpatient stay

 
Co-amoxiclav 625mg PO q8H for 5 days

Or

Amipicillin/Sulbactam 3gm IV q6H

Ceftazidime 2gm IV q8H

+

Metronidazole 500mg IV q8H

OR if severe,

Piperacillin / Tazobactam 4.5 gm IV q6H

 

 
Cefuroxime 1.5 gm IV q8H
+

Metronidazole 500 mg IV q8H

 




Total duration: 7-10 days.
Deescalate antibiotic once culture and sensitivity result is available
IV antibiotics should be de-escalated to oral once clinical improvement occurs (refer to chapter 3.0: ‘Principle of Antibiotic Prescribing’ for  IV to oral conversion options)

Gastrointestinal tract perforation

 

Cefuroxime 1.5gm IV q8H

+

Metronidazole 500mg IV q8H

OR

Ampicillin/sulbactam 1.5-3.0gm IV q8H

OR

Co-amoxiclav 1.2gm IV q8H

Cefoperazone 1-2gm IV q12H

 

+

Metronidazole 500mg IV q8H

Duration 4-7 days (provided there is adequate source control, no delay in surgical intervention and patient has rapid clinical recovery)

Appendicitis

Immediate appendectomy, as opposed to interval appendectomy, should be performed within 12 hours of decision to operate, except in the case of an unstable/septic patient or the presence of free perforation or generalized perforation, where surgery should be performed emergently.

Simple appendicitis/unperforated appendicitis 

Cefuroxime 1.5gm IV q8H

+

Metronidazole 500mg IV q8H

OR

Ampicillin/Sulbactam 1.5gm IV q6H

OR

Co-amoxiclav 1.2gm IV q8H

Penicillin allergy:

IV clindamycin 600-900mg

PLUS

IV gentamicin 5mg/kg

 

 

 

 

Treatment should be discontinued within 24 hours if no evidence of perforation, abscess or local peritonitis.

Perforated appendix/ perforated viscus or intestine/ Appendicular Mass

 (palpable mass in the right lower quadrant on physical examination or by a phlegmon (inflammatory mass) or abscess on imaging studies)

 

Cefuroxime 1.5gm IV q8H

+

Metronidazole 500mg IV q8H

OR

Ampicillin/sulbactam 1.5-3.0gm IV q8H

OR

Co-amoxiclav 1.2gm IV q8H

Cefoperazone 1-2gm IV q12H & Metronidazole 500mg IV q8H

 

 

 

Duration 4-7 days (if adequate source control, no delay in surgical intervention and patient has rapid clinical recovery)

Anal/ rectal abscess

 

Co-amoxiclav 1.2gm IV q8H

Cefuroxime 1.5gm IV q8H & Metronidazole 500mg IV q8H

 

Drainage is required

Duration 4-7 days (if adequate source control, no delay in surgical intervention and patient has rapid clinical recovery)

Trauma

Abdominal trauma/ Stab wound/ suspected bowel or solid organ injury

Common organisms:

Gram negative enteric aerobes and anaerobes

 

 

Co-amoxiclav 1.2gm IV q8H

Cefuroxime 1.5gm IV q8H & Metronidazole 500mg IV q8H

Duration 4-7 days (if adequate source control, no delay in surgical intervention and patient has rapid clinical recovery)

Severe/infected wound:

Piperacillin/tazobactam 4.5gm IV q6H

Severe/infected wound:

Ciprofloxacin 400ng IV q12H & Clindamycin 600mg IV q8H

Vascular

Mycotic aneurysm & Vascular prosthesis infection

 

 

Ceftriaxone 2gm IV q24H

Piperacillin/tazobactam 4.5gm IV q6H

Duration at least 6 weeks (IV then oral based on clinical response and cultures)

Consider adding IV Vancomycin if suspecting MRSA/CoNS vascular prosthesis infection.

Ischemic limb ulcers with infection

 

 

Ampicillin/sulbactam 1.5-3gm IV q6-8H for  7 days

Co-amoxiclav 1.2gm IV q8H for 7 days

May need longer duration if bone infection and  debridement for adequate source control

Soft Tissue

Breast abscess/ Mastitis

Common organism: Staphylococcus aureus

High risk*

 

 

 

 

 

 

Co-amoxiclav 1.2gm IV q8H

OR

Ampicillin/Sulbactam 1.5gm IV q8H

 

 

 

Co-amoxiclav 625mg PO q8H

OR

Ampicillin/sulbactam 750mg PO q12H

 

 

*Patient with

1.    Uncontrolled DM

2.    immunosuppressive therapy

3.    Neutropenia

 

Drainage may be required for abscess

For lactating mastitis: consider sending breastmilk for C+S if not responding after 48 hr of initial antibiotic therapy or recurring mastitis.

Duration 10-14 days but may be shorter if clinically responding.

 

Others

 

Cloxacillin 2gm IV q6H

OR

Cefazolin 1-2gm IV q8H

 

Cloxacillin 1gm PO q6H

OR

Cefalexin 500mg q6H

 

Penicillin allergy

Clindamycin 600mg IV/PO q8H

 

 


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