Written by Megan Hilbert
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The Infectious Diseases Society of America has published an update to clinical practice guidelines in the diagnosis of complicated intra-abdominal infections in various populations.
We do-nut always need to do a CT
A complicated infection was defined as that which extends into the peritoneal cavity, develops peritonitis, or abscess formation. The guidelines (updated from 2010) are as follows:
Adults:
- Severity Illness Score recommended = APACHE II with the World Society of Emergency Surgery Sepsis Severity Score as a viable alternative
- Initial imaging modality recommended:
- Appendicitis – CT (with or without IV contrast; without still has good diagnostic accuracy)
- Acute cholecystitis/cholangitis – ultrasound (US); if equivocal, then pursue CT with IV contrast; if both equivocal, pursue MRI/MRCP or HIDA scan. Diagnosis of cholangitis should always include clinical signs.
- Diverticulitis – CT with IV contrast; if unavailable or contraindicated, US or MRI
- Abscesses – CT with IV contrast
Pediatrics:
- No specific severity illness score was supported
- Initial imaging modality recommended:
- Appendicitis – US, if equivocal, then MRI or CT, NOT repeat US; can also consider clinical observation or exploratory laparoscopy (depending upon discussion with surgeon)
- Abscesses – US, if negative/equivocal can consider CT or MRI
Pregnant:
- Initial imaging modality recommended:
- Appendicitis – US, also reasonable to start with MRI if readily available
- Acute cholecystitis/cholangitis, diverticulitis, abscesses – US or MRI (knowledge gap exists – one not supported over the other)
Any patient population:
- Collect blood cultures? Yes, but only if the patient presents with elevated temperature and hypotension, tachypnea, or delirium, or if there is concern for antibiotic resistant organisms. However, always use your best clinical judgment.
- Collect intra-abdominal cultures? Yes, if doing a procedure for source control. In uncomplicated appendicitis, there is no routine need.
How will this change my practice?
It is easy to jump to the “donut of truth” (CT scan) for the diagnosis of intra-abdominal processes in the majority of our patients. I will feel much more validated in recommending different imaging modalities (depending upon the patient and situation) given the results of these guidelines. While this paper does not address management of these infections, future iterations of the guidelines will. Stay tuned…
Source
2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Risk Assessment, Diagnostic Imaging, and Microbiological Evaluation in Adults, Children, and Pregnant People. Clin Infect Dis. 2024 Oct 4;79(Supplement_3):S81-S87. doi: 10.1093/cid/ciae346. PMID: 38965057
