Table 1: Diagnosis of patients with diffuse abdominal pain

Risk Factors

Presentation

Evaluation

Primary Peritonitis

·        Ascites due to cirrhosis, severe hypoalbuminemia from nephrotic syndrome, CHF, malignancy

·        CAPD catheter

·        VP shunts

·        Diffuse abdominal pain, fever, nausea, vomiting¹

·        Leukocytosis³

·        Other signs and symptoms of hepatic failure⁵

·        Blood cultures⁴

·        AAS

·        Abdominal CT scan

·        Paracentesis²

·        Liver enzymes⁷

·        Amylase, lipase

Secondary Peritonitis

·        Appendicitis

·        Cholecystitis

·        Diverticulitis

·        Peptic ulcer disease

·        Abdominal injury

·        GI neoplasm

·        Bowel obstruction

·        Mesenteric ischemia

·        Surgical anastomotic leak

·        GU infections⁶

·        Acute onset of diffuse abdominal pain, fever, nausea, vomiting

·        Abdomen rigid, hypoactive or absent bowel sounds, guarding and rebound tenderness

·        Leukocytosis³

·        Blood cultures⁴

·        AAS

·        Abdominal CT scan

·        Liver enzymes⁷

·        Amylase, lipase

·        Exploratory laparotomy

Lower Lobe Pneumonia

·        Aspiration

·        Smoking

·        COPD

·        Upper abdominal pain

·        Cough, hypoxia may be present

·        Localized rales on chest examination

·        Blood cultures

·        Chest x-ray

Table 2: Diagnosis of patients with localized abdominal pain

Risk Factors

Presentation

Evaluation

Hepatitis

·        Alcohol ingestion

·        IDU

·        Ingestion of contaminated food

·        RUQ pain

·        Fever, nausea, vomiting

·        Jaundice

·        Liver enzymes⁷

·        Serologic tests for viral hepatitis³

·        Serologic tests for less common causes as indicated⁴

Hepatic abscess

·        Appendicitis

·        Diverticulitis

·        Cholecystitis

·        Bacteremia

·        RUQ and epigastric pain

·        Fever, nausea, vomiting

·        Leukocytosis

·        Blood cultures

·        Liver enzymes⁷

·        RUQ ultrasound

·        CT scan

Cholecystitis¹

·        Gallstones

·        Trauma, burns

·        Postprandial RUQ and epigastric pain

·        Fever, nausea, vomiting

·        (+) Murphy’s sign²

·        Leukocytosis

·        Blood cultures

·        RUQ ultrasound⁵

·        Liver enzymes⁷

·        Amylase, lipase

Cholangitis

·        Obstruction of the biliary tree from gallstones, malignancy, surgery

·        RUQ pain⁶

·        Fever, nausea, vomiting

·        Jaundice

·        Leukocytosis

·        Blood cultures

·        RUQ ultrasound

·        Liver enzymes⁷

·        Amylase, lipase

Appendicitis

·        Generally none

·        Foreign bodies

·        Tumor

·        Strictures

·        Parasitic infection⁸

·        Periumbilical pain migrating to RLQ

·        Fever, nausea, vomiting

·        Leukocytosis

·        CT scan

Diverticulitis

·        Diverticulosis

·        LLQ pain⁹

·        Fever, nausea, vomiting

·        Leukocytosis

·        Blood cultures

·        CT scan

Splenic abscess

·        Bacteremia

·        Endocarditis

·        Sickle cell disease

·        IVDA

·        LUQ pain referred to left shoulder

·        Fever, nausea, vomiting

·        Leukocytosis

·        CT scan

·        CXR¹¹

Colitis¹⁰

·        Contaminated food and water

·        Antibiotics

·        Recent hospitalization

·        Diarrhea, hematochezia

·        RLQ, LLQ pain

·        Fever

·        Leukocytosis

·        Stool culture¹⁰

·        Fecal leukocytes

·        Clostridium difficile toxin assay

Pelvic Inflammatory Disease

·        Young age and  sexual active¹²

·        New sexual partner

·        Bacterial vaginosis

·        IUD

·        RLQ, LLQ pain

·        Fever

·        Leukocytosis

·        Bimanual pelvic examination

·        Pelvic ultrasound

·        CT scan

Endometritis

·        Pregnancy¹³

·        Suprapubic pain

·        Fever

·        Leukocytosis

·        Bimanual pelvic examination

Pancreatic abscess

·        Pancreatitis

·        Periumbilical and back pain

·        Fever

·        Leukocytosis

·        Blood cultures

·        Liver enzymes⁷

·        Amylase, lipase

·        CT scan

Renal abscess

·        Kidney stones

·        Ureteral obstruction

·        DM

·        Bacteremia

·        Flank and back pain

·        Fever

·        Leukocytosis

·        Blood cultures

·        Urine culture

·        Renal ultrasound

·        CT scan

Pyelonephritis

·        Kidney stones

·        Ureteral obstruction

·        DM

·        Flank and back pain

·        Fever, nausea, vomiting

·        Leukocytosis

·        Blood cultures

·        Urine culture

·        Renal ultrasound

Table 3: Microbiology of diffuse peritonitis

Clinical Diagnosis

Community acquired

Hospital acquired

Primary Peritonitis¹

·        E. coli, Klebsiella pneumoniae, Proteus spp, Enterobacter spp

OR

·        S. pneumoniae

OR

·        Streptococci, enterococci

·        Resistant  E. coli, Klebsiella spp, Proteus spp, Enterobacter spp

OR

·        P. aeruginosa

Secondary Peritonitis²

·        E. coli, Klebsiella spp, Proteus spp, Enterobacter spp

AND

·        Enterococci

AND

·        Anaerobes including Bacteroides, Clostridium, Prevotella

·        Resistant  E. coli, Klebsiella spp, Proteus spp, Enterobacter spp, P. aeruginosa, Serratia, Acinetobacter

AND

·        Enterococci including VRE

AND

·        Anaerobes including Bacteroides, Clostridium, Prevotella

AND

·        Candida spp.

Table 4: Microbiology of localized intra-abdominal infections

Clinical Diagnosis

Community Acquired

Hospital Acquired

Diverticulitis

·        Enteric GNR¹

AND

·        Enterococci

AND

·        Anaerobes³ 

·        Resistant  Enteric GNR²

AND

·        Enterococci including VRE

AND

·        Anaerobes³

Appendicitis

Same as diverticulitis

Same as diverticulitis

Pancreatic abscess

Same as diverticulitis

Same as diverticulitis

Cholecystitis

Cholangitis

·        Enteric GNR¹

·        Anaerobes^3,10 

·        Resistant  Enteric GNR²

·        Anaerobes^3,10 

Hepatic abscess⁴

·        Enteric GNR¹

AND/OR

·        Enterococci

AND/OR

·        Anaerobes³

OR

·        S. aureus, Streptococci, Candida, Yersinia⁵

OR

·        Entamoeba histolytica⁶

·        Resistant  Enteric GNR²

AND/OR

·        Enterococci including VRE

AND/OR

·        Anaerobes³

OR

·        S. aureus, Streptococci, Candida,

Splenic abscess⁷

·        S. aureus, Streptococci

·        E. coli, Klebsiella spp, Proteus spp, Enterobacter spp

·        MRSA, VRE

·        Resistant  E. coli, Klebsiella spp, Proteus spp, Enterobacter spp, P. aeruginosa, Serratia, Acinetobacter

Colitis

·        Campylobacter jejuni, Salmonella spp, Shigella spp, E. coli  0157:H7, Vibrio parahaemolyticus, Yersinia enterocolitica ⁸

·        Entamoeba histolytica⁶

·        Clostridium difficile⁹

·        Clostridium difficile⁹

Pelvic Inflammatory Disease

·        Neisseria gonorrhoeae

·        Chlamydia trachomatis

·        Enteric GNR¹ and Anaerobes³

·        Mycoplasma

Not applicable

Endometritis

·        Enteric GNR¹ and Anaerobes³

·        Streptococcus agalactiae

·        Gardnerella vaginalis

·        Resistant  Enteric GNR² and Anaerobes³

·        Streptococcus agalactiae

Renal abscess

·        E. coli, Proteus mirabilis, Klebsiella pneumoniae

·        S. aureus, streptococci

·        Resistant  Enteric GNR²

·        Enterococci including VRE

·        Candida spp

Pyelonephritis

·        E. coli, Proteus mirabilis, Klebsiella pneumoniae

·        Resistant  Enteric GNR²

·        Enterococci including VRE

·        Candida spp

Hepatitis

·        Viral hepatitis A, B,C

·        CMV

Table 6: Antibiotic empiricism for diffuse peritonitis

Clinical Diagnosis

Community Acquired

Hospital

Acquired

Septic Shock

Primary Peritonitis

·        Ceftriaxone

OR

·        Levofloxacin

OR

·        Moxifloxacin

OR

·        Ampicillin-sulbactam

OR

·        Cotrimoxazole

·        Cefepime

OR

·        Levofloxacin

·        Cefepime

AND

·        Levofloxacin

AND

·        Vancomycin

Secondary Peritonitis

due to gastrointestinal perforation

·        Ampicillin-sulbactam

OR

·        Ertapenem (Invanz®)

OR

·        Ceftriaxone

AND

Metronidazole

·        Cefepime

AND

Metronidazole

AND

Vancomycin

OR

·        Piperacillin-tazobactam

OR

·        Imipenem-cilastatin

+/-

·        Fluconazole

·        Cefepime

AND

Ciprofloxacin

AND

Metronidazole

AND

Vancomycin

AND

Fluconazole

Table 7: Antibiotic empiricism for localized intra-abdominal infections

Clinical Diagnosis

Community Acquired

Hospital Acquired

Septic Shock

Diverticulitis

·        Ampicillin-sulbactam

OR

·        Ceftriaxone

AND

Metronidazole

OR

·        Ertapenem (Invanz®)

OR

·        Moxifloxacin

·        Cefepime

AND

Metronidazole

AND

Vancomycin

OR

·        Piperacillin-tazobactam

OR

·        Imipenem-cilastatin

·        Cefepime

AND

Ciprofloxacin

AND

Metronidazole

AND

Vancomycin

Appendicitis

same as diverticulitis

same as diverticulitis

same as diverticulitis

Pancreatic abscess

same as diverticulitis

same as diverticulitis

same as diverticulitis

Cholecystitis

Cholangitis

same as diverticulitis

same as diverticulitis

same as diverticulitis

Hepatic abscess

same as diverticulitis

same as diverticulitis

same as diverticulitis

Splenic abscess

·        Vancomycin

AND

Ceftriaxone

OR

·        Ampicillin-sulbactam

OR

·        Ertapenem

·        Vancomycin

AND

Cefepime

OR

·        Piperacillin-tazobactam

OR

·        Imipenem-cilastatin

·        Vancomycin

AND

Cefepime

OR

·        Piperacillin-tazobactam

OR

·        Imipenem-cilastatin

Colitis

·        Ciprofloxacin

OR

·        Moxifloxacin

OR

·        Co-trimoxazole

OR

·        Metronidazole¹

·        Metronidazole¹

·        Metronidazole¹

Pelvic Inflammatory Disease

·        Ampicillin-sulbactam

AND

Doxycycline

OR

·        Cefotetan

AND

Doxycycline

OR

·        Levofloxacin

AND

Metronidazole

·        Piperacillin-tazobactam

AND

Doxycycline

OR

·        Levofloxacin

AND

Metronidazole

·        Piperacillin-tazobactam

AND

Doxycycline

OR

·        Levofloxacin

AND

Metronidazole

Endometritis

·        Ceftriaxone or Gentamicin

AND

Clindamycin

OR

·        Ampicillin-sulbactam

·        Piperacillin-tazobactam

OR

·        Imipenem-cilastatin

·        Cefepime

AND

Metronidazole

AND

Vancomycin

OR

·        Piperacillin-tazobactam

OR

·        Imipenem-cilastatin

Renal abscess

·        Ceftriaxone

·        Cefepime

AND

Vancomycin

·        Cefepime

AND

Ciprofloxacin

AND

Vancomycin

Pyelonephritis

Same as renal abscess

Same as renal abscess

Same as renal abscess