Blot Stijn, De Waele Jan J
Intensive Care Department, Ghent University Hospital, Belgium.
Drugs. 2005;65(12):1611-20. doi: 10.2165/00003495-200565120-00002.
Intra-abdominal infections differ from other infections through the broad variety in causes and severity of the infection, the aetiology of which is often polymicrobial, the microbiological results that are difficult to interpret and the essential role of surgical intervention. From a clinical viewpoint, two major types of intra-abdominal infections can be distinguished: uncomplicated and complicated. In uncomplicated intra-abdominal infection, the infectious process only involves a single organ and no anatomical disruption is present. Generally, patients with such infections can be managed with surgical resection alone and no antimicrobial therapy besides perioperative prophylaxis is necessary. In complicated intra-abdominal infections, the infectious process proceeds beyond the organ that is the source of the infection, and causes either localised peritonitis, also referred to as abdominal abscess, or diffuse peritonitis, depending on the ability of the host to contain the process within a part of the abdominal cavity. In particular, complicated intra-abdominal infections are an important cause of morbidity and are more frequently associated with a poor prognosis. However, an early clinical diagnosis, followed by adequate source control to stop ongoing contamination and restore anatomical structures and physiological function, as well as prompt initiation of appropriate empirical therapy, can limit the associated mortality. The biggest challenge with complicated intra-abdominal infections is early recognition of the problem. Antimicrobial management is generally standardised and many regimens, either with monotherapy or combination therapy, have proven their efficacy. Routine coverage against enterococci is not recommended, but can be useful in particular clinical conditions such as the presence of septic shock in patients previously receiving prolonged treatment with cephalosporins, immunosuppressed patients at risk for bacteraemia, the presence of prosthetic heart valves and recurrent intra-abdominal infection accompanied by severe sepsis. In patients with prolonged hospital stay and antibacterial therapy, the likelihood of involvement of antibacterial-resistant pathogens must be taken into account. Antimicrobial coverage of Candida spp. is recommended when there is evidence of candidal involvement or in patients with specific risk factors for invasive candidiasis such as immunodeficiency and prolonged antibacterial exposure. In general, antimicrobial therapy should be continued for 5-7 days. If sepsis is still present after 1 week, a diagnostic work up should be performed, and if necessary a surgical reintervention should be considered.
腹腔内感染与其他感染不同，其感染原因和严重程度多种多样，病因通常为多种微生物混合感染，微生物学检查结果难以解读，且手术干预起着至关重要的作用。从临床角度来看，腹腔内感染可分为两大类：非复杂性感染和复杂性感染。在非复杂性腹腔内感染中，感染过程仅累及单一器官，且不存在解剖结构破坏。一般来说，此类感染患者仅通过手术切除即可治疗，除围手术期预防外无需使用抗菌药物治疗。在复杂性腹腔内感染中，感染过程超出感染源器官，根据宿主将感染局限在腹腔一部分的能力，可导致局限性腹膜炎（也称为腹腔脓肿）或弥漫性腹膜炎。特别是，复杂性腹腔内感染是发病的重要原因，且更常与预后不良相关。然而，早期临床诊断，随后进行充分的源头控制以停止持续污染并恢复解剖结构和生理功能，以及及时开始适当的经验性治疗，可降低相关死亡率。复杂性腹腔内感染面临的最大挑战是早期识别问题。抗菌治疗一般已标准化，许多单一疗法或联合疗法方案已证明其有效性。不建议常规覆盖肠球菌，但在特定临床情况下可能有用，例如先前接受头孢菌素长期治疗的患者出现感染性休克、有菌血症风险的免疫抑制患者、存在人工心脏瓣膜以及伴有严重脓毒症的复发性腹腔内感染。对于住院时间长且接受抗菌治疗的患者，必须考虑抗菌药物耐药病原体感染的可能性。当有念珠菌感染证据或存在侵袭性念珠菌病特定风险因素（如免疫缺陷和长期抗菌药物暴露）的患者时，建议覆盖念珠菌属。一般来说，抗菌治疗应持续5 - 7天。如果1周后仍存在脓毒症，应进行诊断性检查，如有必要应考虑再次手术干预。
