Intraabdominal_1.pptxgffggggggggggggjjjjjj

bbv

1. INTRA-ABDOMINAL INFECTIONS Module : Infectious Diseases Dr RUTAGANDA Eric, MD., Mmed ., MPH . Hepato -Gastroenterologist CHUK/ SoM -UR

2. Abscess/Peritonitis Appendicitis Ileo - colitis Diverticulitis Cholecystitis/ Cholangitis / Liver abcess Intra-abdominal infections Surgical/radiological/endoscopic management ++++

3. Cholecystitis Definition : Inflammation of the gallbladder , often due to gallstones blocking the cystic duct . Causes : Most commonly caused by gallstones ; can also result from infection or other factors . Symptoms : Severe abdominal pain ( often in the right upper quadrant) Nausea and vomiting Fever Possible jaundice (if bile duct is involved ) Diagnosis : Typically diagnosed through ultrasound , CT scan, or MRI. Treatment : Often requires surgical intervention ( cholecystectomy ) and antibiotics .

4. Cholangitis Definition : Inflammation of the bile ducts , often due to an infection that occurs when bile ducts are obstructed (e.g., by gallstones or tumors ). Causes : Most commonly caused by a blockage in the bile duct , leading to bacterial infection. Symptoms : Fever and chills Jaundice Abdominal pain ( often in the upper right quadrant) Dark urine and pale stools Diagnosis : Diagnosis typically involves blood tests, imaging studies like ultrasound or MRI, and sometimes ERCP ( endoscopic retrograde cholangiopancreatography ). Treatment : Requires antibiotics and often requires procedures to relieve the blockage (e.g., ERCP, surgical intervention).

5. Bacterial infections associated with cholecystitis and cholangitis In both conditions, bacterial growth is typically due to bile stasis caused by obstruction, which allows for infection to develop . Prompt treatment with antibiotics is crucial to manage them . Escherichia coli (E. coli) : Frequently isolated Klebsiella spp . : Another common pathogen found in infected bile. Enterobacter spp . : Can also be involved , particularly in more severe cases. Enterococcus spp . : Can be involved , particularly in cases with prior antibiotic use. Pseudomonas aeruginosa : More common in hospitalized patients or those with underlying health issues. Bacteroides spp . and Clostridium spp . : May also be present in mixed infections.

6. Rossi & Lefort, Letter from the Infectiologist, 2022 Pyogenic abscesses +++ (Biliary origin+++) Blood culture + diagnostic puncture Front door identification+++ Radiological drainage as first- line treatment if >3-5cm IV treatment then oral relay after 10-14 days – 28 days Amoebic abscess: epidemiological context (endemic/MSM/…) Serology +++ No systematic puncture Metronidazol - 7 days Liver abscess

7. How long should antibiotic treatment last? Cholecystitis Cholecystectomy uncomplicated : 24 hours perforated gallbladder : 3days Grade III ( organ dysfunction ): 3 days Percutaneous drainage: 7 days Not operated or not drained : 7 days Cholangitis with effective drainage : 3 days post-drainage ( even if associated bacteremia ) Reco SPILF – 2021 Infect. Say. Now

8. Diverticulosis : 30% of those over 60 years old 60% of those over 80 years old 25 % of diverticulosis Diverticulitis : Diverticulitis

9. Symptoms Abdominal pain ( usually on the lower left side ) Fever Nausea and vomiting Change in bowel habits ( diarrhea or constipation) Diagnosis Medical History and Physical Exam : Assessing symptoms and examining the abdomen. Imaging Tests : CT Scan : The most common and effective way to confirm diverticulitis and assess its severity . Ultrasound : Sometimes used , particularly in children or pregnant women . Blood Tests : To check for signs of infection or inflammation

10. Treatment Treatment for diverticulitis depends on the severity of the condition: Mild Cases : Dietary Changes : Starting with a clear liquid diet and gradually reintroducing low-fiber foods as symptoms improve . Antibiotics : Often prescribed to treat infection. Moderate to Severe Cases : Hospitalization : May be required for intravenous antibiotics and fluids . Surgery : In cases of complications (like abscesses , perforation, or recurrent diverticulitis ), surgical options include resection of the affected segment of the colon. Long- Term Management : High- Fiber Diet : Once recovery is underway , increasing fiber intake can help prevent future episodes . Regular Exercise : Maintaining an active lifestyle can also reduce risk .

11. Complications of diverticulitis Potential complications of diverticulitis include : Abscess formation Perforation of the colon Peritonitis (infection of the abdominal cavity ) Fistula formation Bowel obstruction

12. APPENDICITIS - What antibiotic therapy? How long? Mr. C., 32 years old, with no history, consults the Emergency Department for pain in the right iliac fossa that has been developing since the previous evening, associated with a fever of 37.8°C. Abdominal examination reveals pain at Mac Burney point. An abdominopelvic CT scan reveals uncomplicated appendicitis

13. Appendicitis Treatment The primary treatment for appendicitis is surgery : Appendectomy : The surgical removal of the appendix , which can be done through open surgery or laparoscopically ( minimally invasive). In some cases of uncomplicated appendicitis , antibiotics alone may be used as a treatment option, but surgery is still generally recommended to prevent recurrence . Complications Perforation : A burst appendix can lead to the spread of infection throughout the abdominal cavity ( peritonitis ). Abscess Formation : Pockets of infection can develop . Bowel Obstruction : Scar tissue or inflammation can lead to blockage of the intestines.

14. Simple appendicitis: no antibiotic treatment post-operatively Gangrenous appendicitis/appendicular abscess: intravenous amoxicillin/clavulanic acid 1g/8h for 48h Appendicular phlegmon: amoxicillin/clavulanic acid IV 1g/8h for 48h + an injection of amikacin 15 to 30mg/kg In case of allergy to beta-lactams: metronidazole 500mg/8h + amikacin 15 to 30mg/kg. In case of complicated form the treatment duration is 1 to 5 days. Appendicitis - What antibiotic therapy? How long?

15. Dysenteric syndrome Or Isolated ileitis Ileocolitis Appendicitis Infectious ileocolitis Infections Biliary/Peritonitis Diverticulitis

16. – Without recent antibiotic therapy Mrs. D., 68 years old, diabetic on diet alone, consults the emergency department for mucous diarrhea associated with pain in the right iliac fossa developing since the previous evening associated with a fever of 37.8°C. An abdominopelvic scan reveals right ileocolitis without complications. She reports a meal with a chicken hamburger 24 hours before the onset of symptoms. You mention infectious ileocolitis ILEOCOLITIS WITHOUT SIGNS OF SEVERITY

17. Disruption of Microbial Balance : Antibiotics can reduce the diversity of gut bacteria , often leading to an imbalance ( dysbiosis ). Beneficial bacteria may be killed off, allowing harmful bacteria to proliferate . Loss of Beneficial Bacteria : Certain antibiotics may particularly affect beneficial species , such as lactobacilli and bifidobacteria . This can result in decreased fermentation of dietary fibers , affecting gut health and function . Overgrowth of Pathogens : Disruption of the normal microbiota can enable pathogenic bacteria (e.g., Clostridium difficile) to thrive , potentially leading to infections such as antibiotic-associated diarrhea or colitis . Short- term and Long- term Effects : While some changes to the microbiota may be temporary and the microbiome can often recover over time, some studies suggest that certain antibiotic courses can have lasting effects on microbial diversity and composition. Individual Variation : The extent of these effects can vary significantly among individuals , influenced by factors such as age , diet , pre-existing health conditions, and the specific antibiotics used . ANTIBIOTIC THERAPY AND IMPACT ON THE INTESTINAL MICROBIOTA

18. by PCR toxin or enzyme immunoassay (GDH + Toxin +) Healthy carriage (3-8% in community setting vs. 20 to 40% in hospital) Variable severity Gram+ anaerobic bacillus , non-invasive 10-25% of simple post-antibiotic diarrhea >120,000 cases/year in Europe and 3,700 deaths/year Pathogenicity linked to the production of two toxins A and/or B Inactive spores (resistance / recurrence) Diagnosis: detection of the toxin+++ • Clostridioides difficile Pseudomembranous colitis Watery diarrhea Bloody-mucous diarrhea Risk of recurrence +++ Kelly, CMI, 2012 – Rank C

19. Risk factor: • Age> 65 years (OR >10!) Hospitalizations Factors modifying the digestive ecosystem: ATB (cephalosporins, penicillins, clindamycin) • PPI/H2 anti- secretor Factors modifying host immunity: Chemotherapy/IBD/Immunosuppression/IRC C. difficile colitis

20. 21 Diagnostic strategies Systematic C. diff toxigenic search in case of : - Dysenteric syndrome - Nosocomial diarrhea - Per/post- Antibiotic diarrhea Always look for it in case of diarrhea >48h No treatment to slow down transit (No loperamide ) Stop Antibiotics and Proton Pump Inhibitors

21. Argument for the interest of fidaxomicin in first- line treatmen t Recurrence at 4 weeks (%) Cornely et al, JAMA 2012 Louie et al, NEJM 2011 Absence of recurrence at D40 (%)

22. Incidence 1-8% of ICD 23 Mortality 10-40% Leukocytes >15 G/L Albumin<30g/L Acute Kidney Disease No response to the VANCOMYCIN +/- FIDAXOMICIN Septic shock Ileus Toxic megacolon Colonic perforation Peritonitis Severe/complicated ICD: Severe Clostridium Difficile Infections (ICD) - Definitions Severe ICD refractory to medical treatment: +

23. Kelly et al, Gastroenterology, 2015 Van Nood et al, NEJM, 2013 Fecal microbiota transplantation in ICD 65

24. Absence of recurrence at D40: 67.1% Cornely et al, JAMA 2012 Van Nood et al, NEJM, 2013 Absence of recurrence at 12 weeks: 75.1% Absence of recurrence at 8 weeks: >90% Wilcox et al, NEJM, 2017 Fecal microbiota transplantation in ICD- the most effective treatment to prevent recurrence FMT Fidaxomicin Bezlotoxumab