An ongoing dialogue on HIV/AIDS, infectious diseases,
January 15th, 2014
Unanswerable Questions in Infectious Diseases: The Abdominal Collection and Duration of Antibiotic Therapy
Each time I attend on the inpatient service, the number of questions for which we just don’t have a definitive answer continues to amaze me. And here’s the most remarkable part — many of them come up all the time!
In that spirit, I will post a series of these quandaries, and you, the brilliant readers, will offer your answers or, barring a definitive answer, your individual approach.
Let’s start with this one:
How long should we continue antibiotics in someone with infected abdominal collection and a percutaneous drain?
You know the situation — peritonitis from perforation, or diverticular abscess, or a surgical mishap, and now the interventional radiologists have kindly placed a drain into the infected collection. (Or, more commonly, multiple drains into the multiple collections.) The patient, once critically ill, is improving — albeit slowly — and the resident, surgical PA, and surgeon all want to know the answer to the above question.
Low grade fevers — 99.5 F or so — continue. There might be an ongoing anastomotic leak, there might not. There is no plan for more surgery. White blood cell count is down from 25K to 15K. Platelets are slowly rising.
Yes, this is a specific variant on the age-old “How long should we treat?” question. I’ve opined on this before, but now we’re getting specific. These IDSA guidelines say “4-7 days,” but that implies rapid source control, no ongoing leak, everything going smoothly.
(And these smooth-sailing cases rarely trigger an ID consult.)
So what do you do in this particular situation? Please vote and comment — especially if you don’t like any of these answers!
I would add one more option based on teaching from one of my esteemed mentors (and original Antimicrobial steward)– Stop antibiotics while drains are draining, then restart for a few days after drains out to “mop up” residual infection.
I usually treat with abx for 10 days after complete and successful drainage of the collection. In my opinion it does not matter how long is the tube placed, since in many instances tube might remain for days or a week or even longer because of continuous draining of some fluid even when the collection is completely disappeared on day one on ct. And on the other hand tube may stop draining and collection might still remain partially undrained.
At first, i would choose 4-7 days (as long as the patient continues to improve and the fever resolves); but since tubes will remain as long as there is some discharge coming out i wonder whether a CT scan can help us to rule out a remaining collection and/or anastomosis leakage (a fact that might convince surgeons to consider a reintervention). This is the kind of patient that should be followed closely and take into consideration all of the above choices. Many thanks Dr Sax, your blog is always awesome.
It depends on whether undrained collection remains in the abdomen. When the collection is not left at all, I treat for 4-7 days according to the IDSA guidelines. On the other hand, I use regimens of at least 3-4 weeks as abdominal abscesses when the collection remains. Therefore, it makes no difference whether drains come out.
I didnt vote because “none of the above” wasn’t an option. Increasing thrombocytosis usually goes with undrained collection and therefore I’d reimage whether drains were in ot out- loculated collections or thick collections can worsen with drains in situ.
Our radiologists are pretty good with trying to sample collections plus-minus leave a pigtail if this “grumbling” kind of presentation is happening. In fact, I saw “this” very patient friday!
I love the “Platelets are slowly rising”, it will bias the results of the poll. For us trainees it depends where we are, who is on service and the lunar phase.
I think this question is impossible to answer and incredibly (individually) patient centered. Thank you Dr. Sax for your amazing observations/blogs/posts…I chuckled while reading your example b/c it’s so true. I agree with 4-7 days in the perfect setting though frequently this is not the case. I would not treat everyone until the drain came out. I would focus on source-control and make every effort to stop thereafter if possible. Sometimes it is, sometimes it isn’t. In my brief stint as an ID Doc, I couldn’t on two patients (ever) stop – eventually weaned off a few – and even let a few younger patient “ride out” their tert bellies and eventually they did quite well, despite a lot of push-back from the surgeons.
I treat my patients when they become a febrile for 72 hours and their WBC shows falling trends. Sometimes the drains keep draining but the patient is clinically well