DIAGNOSIS AND MANAGEMENT OF

INTRATHORACAL AND
INTRAABDOMINAL INFECTION
By:
Fitri Amelia Rizki
Prima Dewi Yuliani

Preceptor:
dr. Liliriawati Ananta Kahar, SpAn, KIC
 CAP HAP - VAP

Fungal IA
Infection infection
 Definition and Epidemiology CAP

•Infection of pulmonary parenchyma

•Symptoms of acute infection
•Chest radiograph: infiltrate
•Patient not hospitalized or residing in a
long-term care facility for more than 14
days before onset of symptoms
•CAP + Influenza 7th leading cause of
death in US
Tabel 1. Most common etiologies of community-acquired pneumonia
Patient type Etiology
Streptococcus pneumoniae
Mycoplasma pneumoniae
Outpatient Haemophilus influenzae
Chlamydophila pneumoniae
Respiratory virusesa
S. pneumoniae
M. pneumoniae
C. pneumoniae
Inpatient (non-ICU) H. influenza
Legionella species
Aspiration
Respiratory virusesa
S. pneumoniae
Staphylococcus aureus
Inpatient (ICU) Legionella species
Gram negative bacilli
H. influenza
Hospital Admission Decision

Pneumonia
Severity Index CURB-65
(PSI)
ICU Admission Decision
•Indication: Severe CAP
•Absolute: Major criteria (1/2)
•Minor criteria: at least 3
criteria
 DIAGNOSIS

Clinical PE Others

• Cough • Rales • Chest

• Fever • Bronchial radiograph
• Sputum breath sounds • Microbiological
production studies
• Pleuritic chest
pain
 Empirical Treatment for CAP

Outpatient Treatment

Inpatient Treatment (non ICU)

Inpatient Treatment (ICU)

Time to First Antibiotic Dose
• Admitted through ED 1st antibiotic dose
should be administered in ED
• 4 h, 8 h
• Duration thy Min: 5 days, should be
afebrile for 48-72 h

Switch IV to PO
• Hemodynamically stable and improving
clinically
Discharge patients
•As soon as clinically stable
•No other active medical
problems
•Safe environment for continued
care
 NONRESPONDING PNEUMONIA

Definition
• A situation in which an inadequate clinical
response is present despite antibiotic
treatment
• Nonresponse to antibiotics in CAP will
generally result in ≥1 of 3 clinical responses:(1)
transfer of the patient to a higher level of care,
(2) further diagnostic testing, and (3)
escalation or change in treatment.
 PREVENTION

inactivated influenza vaccine

intranasally administered live

attenuated vaccine

annual influenza immunization

Pneumococcal polysaccharide
vaccine

Smoking cessation
VAP and HAP
 Diagnostic
• Non-invasive sampling with semiquantitave
cultures.
Invasive Non-invasive
BAL (bronchoalveolar lavage) Spontaneous expectoration
PSB (protected specimen brush) Sputum inductionventilation
Mini-BAL (blind bronchial Nasotracheal suctioning in a
sampling) patient who is unable to
cooperate to produce a sputum
sample
Endotracheal aspiration in a
patient with HAP who
subsequently requires
mechanical ventilation
Gram positive antibiotics
with MRSA activity Empiric Treatment for
• Vancomycin 15 VAP
mg/kgBB IV
• Linezolid 600 mg IV

Gram-Negative antibiotics with

antipseudomnal activity:
Non-β-Lactam-Based Agents
β-Lactam-based agents
Ciprofloxacin 400 mg IV
Piperacillin-tazobactam 4.5 g
Levofloxacin 750 mg IV
Cefepime 2 g IV q8h
Amikacin 10-20mg/kg IV
Ceftazidime 2 g IV q8h
Gentamicin 5-7 mg/kg IV
Imipenem 500 mg IV q6h
Tobramycin 5-7 mg/kg IV
Meropenem 1 g IV q8h
Not at high risk of mortality
and no factors increasing the
likelihood of MRSA
Piperacillin-tazobactam 4,5 g
IV q6h
Cefepime 2 g IV q8h
Levofloxacin 750 mg IV daily
Imipenem 500 mg IV q6h
Meropenem 1 g IV q8h
Not at high risk of mortality
but with factors increasing
the likelihood of MRSA
Piperacillin-tazobactam 4,5 g
IV q6h
Cefepime or ceftazidime 2 g IV Levofloxacin 750 mg IV daily
q8h
Levofloxacin 750 mg IV daily
Ciprofloxacin 400 mg IV q8h
Imipenem 500 mg IV q6h
Meropenem 1 g IV q8h
Aztreonam 2 g IV q8h
Plus:
Vancomycin 15 mg/kg IV q8–
12h
High Risk of Mortality or
Receipt of Intravenous
Antibiotics During the Prior
90 d
Cefepimed or ceftazidimed 2 g
IV q8h
Ciprofloxacin 400 mg IV q8h
Imipenem 500 mg IV q6h
Meropenem 1 g IV Q8h
Amikacin 15–20 mg/kg IV daily
Gentamicin 5–7 mg/kg IV daily
Tobramycin 5–7 mg/kg IV daily
Pathogen spesific therapy
• MRSA VAP/HAP be treated with either
vancomycin or linezolid
• P.aeruginosa should be based upon the result
of antimicrobial susceptibility testing 
aminoglycosides not recommended
• Carbapenem resistant polymyxins B and
inhaled colistin
 Length of therapy
• antimicrobial therapy fo VAP/HAP must be at
least 7 days
Pulmonary Fungal Infection
 Risk Patient

Hematologic
Malignancy
disease

Immuno-
HIV suppressive
drugs
 POLYENES

Amphotericin B deoxylate
(amphotericin B)

Liposomal amphotericin B

Amphotericin B lipid complex

 TRIAZOLE

Ketoconazole

Itraconazole

Fluconazole

Voriconazole

Posazonazole
 ECHINOCANDINS

Caspofungin

Micafungin

Anidulafungin
Intra-Abdominal Infection
 INITIAL DIAGNOSTIC

• Routine history, physical examination, and laboratory

studies
• Diffuse peritonitis and in whom immediate surgical
intervention is to be performed --> further diagnostic
imaging is unnecessary

Resucitation

• Should undergo rapid restoration of intravascular

volume and additional measures as needed to promote
physiological stability.
• Septic shock--> resuscitation begin immediately when
hypotension is identified
• Without evidence of volume depletion --> intravenous
fluid therapy should begin when the diagnosis of intra-
abdominal infection is first suspected.
 Microbiologic Evaluation

• Blood cultures do not provide additional

clinically relevant information for patients
with community-acquired intraabdominal
infection and are therefore not routinely
recommended for such patients.
• Routine Gram stain --> No proven value
• Anaerobic cultures are not necessary if
empiric antimicrobial therapy active against
common anaerobic pathogens is provided.
Recommended regimen for health care-
associated intra-abdominl infection
 Antifungal Therapy

• Recommended if Candida is grown from intra-

abdominal cultures
• Fluconazole --> appropriate treatment for Candida
• For fluconazole-resistant Candida species, therapy with
an echinocandin (caspofungin, micafungin, or
anidulafungin)

Anti-enterococcal Therapy

• Ampicillin, piperacillintazobactam, and vancomycin.

• Empiric therapy directed against vancomycin-resistant
Enterococcus faecium is not recommended --> unless
the patient is at very high risk for an infection due to
this organism
 Anti MRSA

• Vancomycin

Cholecystitis and Cholangitis

• Ultrasonography --> first imaging

• Patients with suspected infection and either acute
cholecystitis or cholangitis should receive
antimicrobial therapy, although anaerobic therapy is
not indicated unless a biliary-enteric anastamosis is
present
 Duration of Therapy
• Antimicrobial therapy of established infection should be
limited to 4–7 days.
• Delayed operation for acute stomach and proximal jejunum
perforations, presence of gastric malignancy or presence of
therapy reducing gastric acidity, antimicrobial therapy to
cover mixed flora should be provided.
• Acute appendicitis without evidence of perforation, abscess,
or local peritonitis requires only prophylactic administration
of narrow spectrum regimens active against aerobic and
facultative and obligate anaerobes; treatment should be
discontinued within 24 h
THANK YOU