INFECCIONES INTRAABDOMINALES Jornadas Colombo-Venezolanas de Cirug a Septiembre 2005

1. INFECCIONES INTRAABDOMINALES Jornadas Colombo-Venezolanas de Cirug�aSeptiembre 2005 Francisco P�rez Internista Infect�logo Adjunto II Servicio Medicina Interna Hospital Dr. Patrocinio Pe�uela Ruiz San Crist�bal. Estado T�chira

2. INFECCI�N INTRAABDOMINAL � Es la respuesta inflamatoria del peritoneo a los microorganismos y a sus toxinas, lo cual resulta en un exudado purulento en la cavidad abdominal�

3. Peritoneo

4. Factores determinantes en la patog�nesis de la Infecci�n Intraabdominal Tipo y n�mero de bacterias Sinergismo bacteriano Obstrucci�n Hemoglobina y pigmentos biliares Cuerpos extra�os Factores sist�micos: Comorbilidad Respuesta inflamatoria

5. Clasificaci�n de las Infecciones Intraabdominales

6. Gu�as Infections Diseases Society American Surgical Infection Society American Society for Microbiology Society of Infectious Disease Pharmacists Prevent Antimicrobial Resistance in Helthcare CDC Clinical Infectious Diseases. 2003; 37:997-1005 Joseph Solomkin, John Mazuski, Ellen J. Baron, Robert G. Sawyer, Avery Nathens, Joseph Di Piro, Timothy Buchman, E Dillinger, John Jernigan, Sherwood Gorbach, Anthony Chow and John Barlett

7. INFECCI�N INTRAABDOMINALCLASIFICACI�N IDSA 2003 Infecci�n adquirida en la comunidad: principalmente Gram Negativos aerobios y en severidad Anaerobios Infecci�n Postoperatoria (Nosocomial): flora m�s resistente: Pseudomonas aeruginosa, Enterobacter sp, Proteus sp, Staphylococcus aureus Oxacilino resistente, Enterococcus sp, y Candida sp.

8. Puntos evaluados Sitio de origen Microbiolog�a Diagn�stico de laboratorio Selecci�n Antibi�tica Duraci�n del tratamiento

9. PRONOSTICO DE LA INFECCION INTRABDOMINAL La morbilidad y mortalidad de la INFECCION INTRABDOMINAL depende de: Origen de la infecci�n Tiempo de inicio del tratamiento Adecuada soluci�n quir�rgica Uso adecuado de antibi�ticos emp�ricos en el momento inicial Edad del paciente y enfermedades subyacentes

10. Mortalidad Asociada con IIA: Perforaci�n Aguda Peritonitis La mortalidad asociada a perforaci�n aguda: peritonitis es muy relacionada al sitio y severidad de la perforaci�n y varia entre 1.1% y 21.0%. Key Message: The mortality associated with acute perforation peritonitis is largely related to site and severity of perforation and varies between 1.1% and 21.0%. Mortality is highest for colonic perforation. Speaker Notes: Hospital mortality after simple closure of perforated gastric ulcers was 10% and that after resection was 7.5% (Hewitt, 1993). Perforation of gallbladder at higher age was associated with increased mortality (Andersson, 1990). Study Methodology: Hewitt, 1993 Date of Data: 1969-1988 Study Methods: Retrospective review of patients with perforated gastric ulcers that underwent emergency surgery Sample Size: 134 patients Sites Used: South Africa (Groote Schuur Hospital, Cape Town) Sampling Method: Nature of ulcer and site of perforation were determined by reviewing operative and pathology reports Mosdell, 1991 Date of Data: January 1, 1987 � December 31, 1989 Study Methods: Retrospective chart review of patients with secondary bacterial peritonitis admitted to 5 largest hospitals in Albuquerque, New Mexico Sample Size: 480 patients with secondary bacterial peritonitis Sampling Method: Charts of 480 patients with secondary bacterial peritonitis were reviewed to determine morbidity and mortality rates by anatomical site. Andersson, 1990 Date of Data: 1969-1986 Study Methods: Review of all patients treated for acute cholecystitis admitted to two hospitals in Sweden Sample Size: 5,848 patients with cholecystitis Sites Used: Two hospitals in Sweden Sampling Method: Retrospective review of 104 patients that had bile within the abdomen at operation. Luckmann, 1989 Study Methods: Retrospective analysis of hospital discharge abstracts from Californian hospitals Sample Size: 24,794 patients Sites Used: US Sampling Method: Hospital abstracts for patients undergoing appendectomies and abscess drainage procedures performed for acute appendicitis were analyzed. Definition of Terms: IAI: Intra-Abdominal Infection Source Verification Key: TBD Key Message: The mortality associated with acute perforation peritonitis is largely related to site and severity of perforation and varies between 1.1% and 21.0%. Mortality is highest for colonic perforation. Speaker Notes: Hospital mortality after simple closure of perforated gastric ulcers was 10% and that after resection was 7.5% (Hewitt, 1993). Perforation of gallbladder at higher age was associated with increased mortality (Andersson, 1990). Study Methodology: Hewitt, 1993 Date of Data: 1969-1988 Study Methods: Retrospective review of patients with perforated gastric ulcers that underwent emergency surgery Sample Size: 134 patients Sites Used: South Africa (Groote Schuur Hospital, Cape Town) Sampling Method: Nature of ulcer and site of perforation were determined by reviewing operative and pathology reports Mosdell, 1991 Date of Data: January 1, 1987 � December 31, 1989 Study Methods: Retrospective chart review of patients with secondary bacterial peritonitis admitted to 5 largest hospitals in Albuquerque, New Mexico Sample Size: 480 patients with secondary bacterial peritonitis Sampling Method: Charts of 480 patients with secondary bacterial peritonitis were reviewed to determine morbidity and mortality rates by anatomical site. Andersson, 1990 Date of Data: 1969-1986 Study Methods: Review of all patients treated for acute cholecystitis admitted to two hospitals in Sweden Sample Size: 5,848 patients with cholecystitis Sites Used: Two hospitals in Sweden Sampling Method: Retrospective review of 104 patients that had bile within the abdomen at operation. Luckmann, 1989 Study Methods: Retrospective analysis of hospital discharge abstracts from Californian hospitals Sample Size: 24,794 patients Sites Used: US Sampling Method: Hospital abstracts for patients undergoing appendectomies and abscess drainage procedures performed for acute appendicitis were analyzed. Definition of Terms: IAI: Intra-Abdominal Infection Source Verification Key: TBD

11. Mortalidad Asociada con IIA: Peritonitis Post-Traumatica La mortalidad asociada con Peritonitis post-traum�tica es aproximadamente 33%. Key Message: The mortality associated with post-traumatic peritonitis is high, at approximately 33%. Study Methodology: Date of Data: 1973-1977 Study Methods: Retrospective review of patients undergoing operation for intraabdominal abscess Sample Size: 143 patients, 57 patients with intraabdominal abscess due to trauma Sites Used: US (Louisville General Hospital) Sampling Method: Records from patients undergoing operation for intraabdominal abscess were reviewed. Factors associated with a fatal outcome were evaluated from among numerous clinical variables. Definition of Terms: IAI: Intra-Abdominal Infection Source Verification Key: TBD Key Message: The mortality associated with post-traumatic peritonitis is high, at approximately 33%. Study Methodology: Date of Data: 1973-1977 Study Methods: Retrospective review of patients undergoing operation for intraabdominal abscess Sample Size: 143 patients, 57 patients with intraabdominal abscess due to trauma Sites Used: US (Louisville General Hospital) Sampling Method: Records from patients undergoing operation for intraabdominal abscess were reviewed. Factors associated with a fatal outcome were evaluated from among numerous clinical variables. Definition of Terms: IAI: Intra-Abdominal Infection Source Verification Key: TBD

12. Consideraciones Toxicidad espec�fica del agente o dependiente del hu�sped Superinfecci�n Organismos intr�nsicamente resistentes Presi�n selectiva en el Hospital, UCI o incluso en la comunidad. Aparici�n de BLEE cada d�a m�s frecuente.

13. Cuales pacientes requieren administraci�n terap�utica de antibi�ticos? Perforaci�n o trauma agudo intestinal = ATB por 24 horas Perforaci�n aguda Est�mago, Duodeno o Yeyuno proximal = ATB por 24 horas Apendicitis aguda sin evidencia de gangrena, perforaci�n, absceso o Peritonitis = 24 horas con ATB activo contra Gram Neg y anaerobios obligados Colecistitis aguda: Enterobacterias. Sin afectaci�n por Enterococo o Anaerobios Pancreatitis Necrotizante: flora similar a la de Perforaci�n col�nica

14. Inicio de Tratamiento emp�rico Infecci�n establecida: Presencia de respuesta inflamatoria sist�mica y local, �sta �ltima indicada por la presencia de exudado purulento e inflamaci�n tisular. Ahora es apropiado iniciar antibioticoterapia, incluso antes de obtener resultados de cultivos bacteriol�gicos. Su objetivo es: -Eliminar microorganismos infectantes -Disminuir la posibilidad de recurrencias -Acortar el tiempo de resoluci�n de signos y s�ntomas de la infecci�n

15. MODELO ANIMAL DE INFECCION INTRAABDOMINAL.Weinstein,Onderdonk,Barlett.1974 La implantaci�n intraabdominal de contenido fecal en ratas ocasiona una enfermedad de dos fases. Mueren en las primeras 24 horas, por bacteremia por Escherichia coli Los animales sobrevivientes, desarrollan abscesos a los 5-7 d�as, con crecimiento predominante de Bacteroides fragilis

16. INFLUENCIA DEL INICIO DEL TRATAMIENTO CON ANTIBIOTICOS Y PRONOSTICO En modelos experimentales de infecci�n intraabdominal, asi como la experiencia cl�nica demuestran que el pron�stico en morbilidad y mortalidad de esta condici�n empeora si se retrasa en cuatro horas o m�s el inicio de los antibi�ticos y la soluci�n del problema quir�rgico

17. Uso adecuado de antibi�ticos emp�ricos en el momento inicial!!!!

18. REQUISITOS PARA UN ANTIBIOTICO EN INFECCION INTRAABDOMINAL EFICACIA !!!!! Debe ser activo contra los organismos responsables Si, adem�s, es f�cil de administrar, no estimula el desarrollo de resistencia, tiene pocos efectos secundarios y hay ventajas en la relaci�n COSTO/BENEFICIO, mucho mejor

19. Patr�n de actividad de los principales antimicrobianos frente a los microorganismos implicados con mayor frecuencia en las infecciones intraabdominales

20. Terapia Emp�rica adecuada para IAA: �xito Pron�stico cl�nico En IAA pacientes con Terapia emp�rica apropiada son significativamente m�s susceptibles de pron�stico cl�nico adecuado Key Message: IAI patients with appropriate empiric therapy are significantly more likely to have successful clinical outcome. Speaker Notes: Appropriate therapy was defined as: Positive peritoneal swabs: All bacteria sensitive to at least one empirical drug Negative or no peritoneal swab: Regimen covering both aerobic and anaerobic bacteria Inappropriate therapy was defined as: Positive peritoneal swabs: One or more bacteria resistant to all of the antibiotics used for empiric therapy Negative or no peritoneal swab: Empirical treatment without activity against both aerobic and anaerobic bacteria Successful outcome was defined as resolution with no change in treatment. Unsuccessful outcome was defined as resolution with downscale, death, or infection Study Methodology: Date of Data: 1993-1997 Study Methods: Records of 348 patients were reviewed Empiric IAI antibiotic treatment was classified as appropriate or inappropriate, successful or unsuccessful (or unevaluable) Sample Size: 348 patients, 294 evaluable for clinical success Sites Used: 3 hospitals in Scotland Sampling Method: Records were reviewed independently by two infectious disease specialists to check validity of diagnosis and assess appropriateness of empirical antibiotic treatment and classify outcome Definition of Terms: IAI: Intra-Abdominal Infection Source Verification Key: TBD Key Message: IAI patients with appropriate empiric therapy are significantly more likely to have successful clinical outcome. Speaker Notes: Appropriate therapy was defined as: Positive peritoneal swabs: All bacteria sensitive to at least one empirical drug Negative or no peritoneal swab: Regimen covering both aerobic and anaerobic bacteria Inappropriate therapy was defined as: Positive peritoneal swabs: One or more bacteria resistant to all of the antibiotics used for empiric therapy Negative or no peritoneal swab: Empirical treatment without activity against both aerobic and anaerobic bacteria Successful outcome was defined as resolution with no change in treatment. Unsuccessful outcome was defined as resolution with downscale, death, or infection Study Methodology: Date of Data: 1993-1997 Study Methods: Records of 348 patients were reviewed Empiric IAI antibiotic treatment was classified as appropriate or inappropriate, successful or unsuccessful (or unevaluable) Sample Size: 348 patients, 294 evaluable for clinical success Sites Used: 3 hospitals in Scotland Sampling Method: Records were reviewed independently by two infectious disease specialists to check validity of diagnosis and assess appropriateness of empirical antibiotic treatment and classify outcome Definition of Terms: IAI: Intra-Abdominal Infection Source Verification Key: TBD

21. Terapia apropiada Vs Inapropiada para IAA: Mortalidad Terapia antibi�tica emp�rica apropiada para IIA es asociada con Mortalidad hospitalaria sustancialmente baja. Key Message: Appropriate empiric antibiotic therapy for IAI is associated with substantially lower hospital mortality. Speaker Notes: A patient was classified as having received inadequate therapy if at least one clinically relevant pathogen was not susceptible to the initial regimen. A patient was classified as having received adequate therapy if all clinically relevant pathogens identified from the patient within 48 hours of hospital admission were susceptible to the initial antibiotic regimen. Study Methodology: Date of Data: 1990-1999 Study Methods: Retrospective analysis of computerized patient medical records from a large health care system, using all available hospital databases Included all adult hospitalized patients treated with parenteral antibiotics for IAI Sample Size: 428 patients Sites Used: US (Utah) Sampling Method: Patient discharge diagnosis was used to identify the patients. Definition of Terms: IAI: Intra-Abdominal Infection Source Verification Key: TBD Key Message: Appropriate empiric antibiotic therapy for IAI is associated with substantially lower hospital mortality. Speaker Notes: A patient was classified as having received inadequate therapy if at least one clinically relevant pathogen was not susceptible to the initial regimen. A patient was classified as having received adequate therapy if all clinically relevant pathogens identified from the patient within 48 hours of hospital admission were susceptible to the initial antibiotic regimen. Study Methodology: Date of Data: 1990-1999 Study Methods: Retrospective analysis of computerized patient medical records from a large health care system, using all available hospital databases Included all adult hospitalized patients treated with parenteral antibiotics for IAI Sample Size: 428 patients Sites Used: US (Utah) Sampling Method: Patient discharge diagnosis was used to identify the patients. Definition of Terms: IAI: Intra-Abdominal Infection Source Verification Key: TBD

22. USO ADECUADO DE ANTIBIOTICOS Y PRONOSTICO INFECCION INTRAABDOMINAL. DATOS VENEZOLANOS Pi�ango Silvia, Viteri Y, Urdaneta C, Wertheimer A and Sen S.: Association between appropiate initial therapy and clinical outcome among patients undergoing surgery for Community-acquired intraabdominal infection in Venezuela. Abstract 06146. ICID, Cancun, Mexico, March 2004 Se revisaron 400 pacientes entre Octubre 1998 y Agosto del a�o 2002, atendidos en el hospital dr. Domingo Luciani. 66% de los pacientes con terapia apropiada tuvieron curso favorable, contra 41% de los que recibieron terapia inapropiada

23. USO DE ANTIBIOTICOS EMPIRICOS EN INFECCION INTRABDOMINAL �DEPENDE DEL CONOCIMIENTO DE LA MICROBIOLOGIA�

24. MICROBIOLOGIA DE LA INFECCION INTRAABDOMINAL. Solomkin et al. 2003 En 396 pacientes analizados: AEROBIOS: Escherichia coli 279 Klebsiella spp. 52 Pseudomonas aeruginosa 51 Enterococcus sp. 102 ANAEROBIOS Bacteroides 448 Clostridium 130

25. MICROBIOLOGIA DE LA INFECCION INTRAABDOMINAL (1) A pesar de la compleja microbiolog�a intestinal, Escherichia coli entre los facultativos y Bacteroides fragilis entre los anaerobios, tienden a predominar en la INFECCI�N INTRAABDOMINAL ADQUIRIDA EN LA COMUNIDAD El aislamiento inicial de Pseudomonas aeruginosa o Enterobacter cloacae puede tener significaci�n evolutiva

26. MICROBIOLOGIA DE LA INFECCION INTRAABDOMINAL (2) Candida spp, Enterococo, Pseudomonas aeruginosa y Enterobacterias resistentes son responsables de fallas al esquema de tratamiento en pacientes con INFECCION INTRABDOMINAL DE ORIGEN NOSOCOMIAL Drenaje inadecuado de colecciones es causa m�s frecuente de fiebre persistente que falla del esquema de antibi�ticos

27. Microbiologia de la infeccion intraabdominal. Rossi et al. Studio SMART (LA), 2003. Presentado en XII API, Caracas, Mayo 2005 776 AISLAMIENTOS EN PACIENTES DE SEIS PAISES. Escherichia coli 55% Klebsiella spp. 14% Pseudomonas . 9% Enterobacter sp. 8% Citrobacter 5% Pacientes con infecci�n adquirida en la comunidad

29. Aislamientos. Abdomen. 2004Programa de Vigilancia de Resistencia Venezuela

30. �HACEN FALTA CULTIVOS PARA LA SELECCI�N INICIAL DE ANTIBIOTICOS EN INFECCION INTRAABDOMINAL? El momento cr�tico de selecci�n de antibi�ticos es en las primeras 24 horas, cuando no hay resultado de cultivo disponible Por lo tanto, la selecci�n debe ser emp�rica, pero basada en PATRONES LOCALES DE SENSIBILIDAD La vigilancia de resistencia es muy importante para adecuada selecci�n inicial, SOLO POSIBLE SI HAY CULTIVOS !!!

31. RECOMENDACIONES IDSA 2003 SOBRE REALIZACION CULTIVOS INFECCION INTRAABDOMINAL NO cultivos de rutina en pacientes con Apendicitis Cultivos en otras infecciones, para identificar organismos ent�ricos facultativos NO cultivos rutinarios de anaerobios, pero si conocer patrones locales de susceptibilidad de Bacteroides fragilis Solomkin et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clinic Infect Dis. 2003; 37:997-1005

33. PATRONES DE RESISTENCIA PROTAGONISTAS PRINCIPALES Escherichia coli Bacteroides fragilis Klebsiella pneumoniae Pseudomonas aeruginosa Enterocococcus faecalis Candida sp

34. Escherichia coli. Abdomen.2004. Sensibilidad. Venezuela Fuente: Programa Venezolano de Resistencia Bacteriana

35. Pseudomonas aeruginosa. Abdomen.2004. Sensibilidad. Venezuela Fuente: Programa Venezolano de Resistencia Bacteriana

36. Staphylococcus aureus. Abdomen.2004. Sensibilidad. Venezuela Fuente: Programa Venezolana de Resistencia Bacteriana

37. Klebsiella pneumoniae. Abdomen.2004. Sensibilidad. Venezuela Fuente: Programa Venezolano de Resistencia Bacteriana

38. ESBL PRODUCING GNB IN INTRA-ABDOMINAL INFECTION. SMART study 2003 (Latin America). Rossi et al. Presentado en XII API, Caracas, Mayo 2005 Escherichia coli 10% (8% menos 48h) Klebsiella pneumoniae 14% (12% menos 48h)

39. Dinubile et al. Results from SMART 2003. Abstract C2-1329-2004; ICAAC, Washington, 2004 NORTH AMERICA 3% LATINAMERICA 10% EUROPE 7% ASIA/PACIFIC 18% ESBL PRODUCING Escherichia coli INPATIENTS WITH COMMUNITY ACQUIREDINTRAAABDOMINAL INFECTIONS.

40. Distribution of ESBL phenotypes in the SENTRY Antimicrobial Surveillance Program (2002 and 2003)

41. Identificaci�n de pacientes de Riesgo alto Pobre estado nutricional Scores APACHE altos Enfermedad Cardiovascular significativa Terapia de transplante Cancer Prolongada estad�a preoperatoria y ATB > 2 d�as Pre: Predictores significativos de falla cl�nica, con infecci�n recurrente, por g�rmenes ya resistentes

42. Selecci�n de reg�menes emp�ricos de antibi�ticos Infecci�n de Est�mago, duodeno, tracto biliar e intestino delgado proximal: Gram negativos y Gram Positivos aer�bicos y facultativos. Intestino delgado distal Gram Negativos facultativos y aer�bicos en forma variable. Aparece B fragilis. Colon: Anaerobios obligados y facultativos. Estreptocos y Enterococos

43. En IIA adquirida en la comunidad: actividad contra ent�ricos Gram Negativos aer�bicos, bacilos facultativos y cocos Gram positivos sensibles Betalact�micos. Se asocia bacilos anaerobios obligados en origen intestino distal, colon o presencia de obstrucci�n.

44. Apropiada Vs Inapropiada Terapia: Guias Tratamiento IIA (SIS, 2002) Guias publicadas por SIS fueron revisadas en 2002 e incluyen los siguientes reg�menes antimicrobianos recomendados: Key Message: The most recent guidelines published by SIS in 2002 added the following recommended antimicrobial regimens: Single agents: Ampicillin/sulbactam, ertapenem, meropenem (severe infections), piperacillin/tazobactam (severe infections) Combination therapy: Cefuroxime + metronidazole, ciprofloxacin + metronidazole Study Methodology: Study Methods: Literature published between 1990 and 2000 related to antimicrobial therapy for IAIs was reviewed and categorized by the Therapeutics Agents Committee of the Society. Provisional guidelines for antimicrobial therapy for IAI were developed by a process of iterative consensus. Guidelines were approved for publication in final form by the Council of the SIS. Definition of Terms: SIS: Surgical Infection Society IAI: Intra-Abdominal Infection Source Verification Key: TBD Key Message: The most recent guidelines published by SIS in 2002 added the following recommended antimicrobial regimens: Single agents: Ampicillin/sulbactam, ertapenem, meropenem (severe infections), piperacillin/tazobactam (severe infections) Combination therapy: Cefuroxime + metronidazole, ciprofloxacin + metronidazole Study Methodology: Study Methods: Literature published between 1990 and 2000 related to antimicrobial therapy for IAIs was reviewed and categorized by the Therapeutics Agents Committee of the Society. Provisional guidelines for antimicrobial therapy for IAI were developed by a process of iterative consensus. Guidelines were approved for publication in final form by the Council of the SIS. Definition of Terms: SIS: Surgical Infection Society IAI: Intra-Abdominal Infection Source Verification Key: TBD

45. GUIAS PARA TRATAMIENTO INFECCION INTRAABDOMINAL ADQUIRIDA EN LA COMUNIDAD. IDSA. 2003 INFECCION LEVE A MODERADA Ampicilina/ Sulbactam Ertapenem Cefazolina m�s Metronidazole Ciprofloxacina , Levofloxacina o Moxifloxacina m�s Metronidazole INFECCION SEVERA Piperacilina/ Tazobactam Cefoperazona /Sulbactam Imipenem o Meropenem Cefotaxima o Cefepime m�s Metronidazole Ciprofloxacina m�s metronidazole Aztreonam m�s Metronidazole

46. Tips!!!!! Aminogluc�sidos NO son recomendados para uso de rutina en IAA adquiridas en la comunidad. Se basa en su toxicidad. Si en Alergias a Betalact�micos o IIA nosocomial. Cefoxitin, clindamicina: incremento importante de la resistencia a B. fragilis

47. Duraci�n del tratamiento Hasta la resoluci�n de los signos cl�nicos de Infecci�n, con normalizaci�n de la temperatura y de la cuenta blanca, y retorno de la funci�n gastrointestinal. Persisten signos de infecci�n despu�s de 5-7 d�as = Revisar (Imagenolog�a)

48. SUGERENCIAS PARA INICIO DE TRATAMIENTO 2005 INFECCION NO COMPLICADA, INICIO DE TRATAMIENTO EN LAS PRIMERAS 4 HORAS: Agente �nico: Ampicilina/Sulbactam � Cefoxitin � Cefoperazona/Sulbactam, Piperacilina/Tazobactam � � Ertapenem. Tener en cuenta patrones locales de resistencia INFECCION SEVERA, PERFORACION COLONICA O GASTRICA, MAS DE CUATRO HORAS: Esquema combinado, incluyendo CARBAPENEM (Meropenem � Imipenem o Ertapenem) o CEFOPERAZONA /SULBACTAM � PIPERACILINA/TAZOBACTAM O METRONIDAZOL y un aminoglic�sido. Cobertura de Enterococcus faecalis de acuerdo a resultados PERITONITIS TERCIARIA: Imprescindible tener resultados de MICROBIOLOGIA

49. INFLUENCIA DE RESISTENCIA EN PRONOSTICO. Peritonitis terciaria Montravers P et al. �Emergence of antibiotic-resistance bacteria in cases of peritonitis after intraabdominal surgery affects the efficacy of empirical antimicrobial therapy�. Clin Infect Dis, 1996;23:486-494 100 organismos resistentes fueron aislados de 70 pacientes, de los cuales 45% murieron, contra 16% de los que ten�an organismos sensibles a la terapia emp�rica El n�mero de reintervenciones y la estancia hospitalaria fue mayor en el grupo con terapia emp�rica inapropiada

50. Peritonitis Primaria

51. Microbiolog�a de la Peritonitis Primaria

52. Abscesos Intraabdominales � Los abscesos intraabdominales se forman fundamentalmente en los espacios subfr�nicos y en el saco de Douglas. En los pacientes operados electivamente, los abscesos suelen localizarse en las proximidades del �rgano intervenido Los abscesos tienen su origen m�s frecuente en la extravasaci�n o vertido del contenido intestinal en el peritoneo como consecuencia de la perforaci�n de una v�scera hueca espont�nea o secundaria a una dehiscencia anastom�tica o a un traumatismo con lesi�n visceral

53. Microbiolog�a de los abscesos intrabdominales postoperatorios

54. Infecci�n V�as Biliares La patolog�a de las v�as biliares est� muy ligada a la litiasis y la obstrucci�n COLECISTITIS. Se produce en m�s del 90% de los casos por obstrucci�n del conducto c�stico, habitualmente por litiasis que desencadena la inflamaci�n de la ves�cula. Sin embargo, la presencia de colelitiasis aislada no es suficiente para producir colecistitis COLANGITIS. A diferencia de la colecistitis la causa primaria de la colangitis es la infecci�n. Con la obstrucci�n, la elevaci�n de la presi�n promueve la migraci�n de las bacterias de la bilis a la circulaci�n sist�mica desencadenando una bacteriemia y sepsis.

55. Espectro de bacterias aisladas en bilis y sangre de pacientes con colangitis.(%)

56. CONTROL RESISTENCIA A LOS ANTIBIOTICOS No hay sustituto al uso juicioso de los antibi�ticos, con indicaciones precisas y soporte microbiol�gico siempre que sea posible

57. GRACIAS