Antibiotics for Intra-Abdominal Infections: When, Which, How and How Long?

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Intra-abdominal infections (IAIs) are among the most challenging problems in surgical practice, ranging from uncomplicated appendicitis to life-threatening peritonitis. IAIs require prompt diagnosis, timely surgical intervention, and appropriate antimicrobial therapy.

Antibiotics are essential in IAIs management. For years, an empirical broad-spectrum approach, often with prolonged courses of multiple agents, has been the default response to IAIs. This approach certainly saved lives. However, it has promoted the selection of multidrug-resistant organisms.

Prescribing antibiotics in IAIs is challenging: it requires a balance between urgency and precision, between lifesaving therapy and the long-term threat of antimicrobial resistance (AMR). Antibiotic therapy should be individualised and tailored on the patient’s clinical conditions and the local epidemiology.

In community-acquired IAIs, narrow-spectrum coverage is often sufficient, avoiding unnecessary exposure to carbapenems or anti-pseudomonal agents. In contrast, healthcare-associated infections, especially in patients with previous antibiotic exposure or serious illness, may need a broader empiric approach, followed by de-escalation once cultures clarify the microbiologic picture.

For these reasons, in a narrative review recently published in Antibiotics, Massimo Sartelli and his collaborators tried to answer four questions.

When should antibiotics be used in patients with IAIs? Which antibiotics should be selected? How should they be managed? How long should they be administered in patients with IAIs?

The authors concluded that advances in antibiotic agents, optimised pharmacokinetics and pharmacodynamics strategies, and stewardship-driven de-escalation provide opportunities to improve efficacy while preserving future antibiotic utility in an era of increasing AMR.

Reference

Sartelli M, Palmieri M, Labricciosa FM. Antibiotics for Intra-Abdominal Infections: When, Which, How and How Long? Antibiotics. 2025;14(11):1127.

Epidemiological analysis of intra-abdominal infections in Italy: the IRIS study

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Intra-abdominal infections (IAIs) are common and serious surgical emergencies. Over the past few years, an increase in antimicrobial resistance (AMR) associated with IAIs has been observed worldwide, responsible for a significant increase in morbidity and mortality rates, and overall healthcare costs. In order to improve the quality of treatment, it is essential to recognize the underlying local epidemiology, clinical implications, and appropriate management of AMR.

In a paper recently published in the World Journal of Emergency Surgery, a prospective, observational, nationwide, multicentre study was conducted to investigate the epidemiology and initial management of complicated IAIs (cIAIs) in Italy.

The IRIS study (Italian Register of Complicated Intra-abdominal InfectionS) included 4,530 consecutively hospitalized patients – older than 16 years of age – from 23 different Italian hospitals, between May 1, 2021 and April 31, 2023, with diagnosis of cIAIs undergoing surgery, interventional drainage or conservative treatment.

Overall, 70.9% of the cases were community acquired infections, the predominant type of infection for all the diagnosis. The majority of healthcare-associated infections were represented by colonic perforation and diverticulitis (28.3%), small bowel occlusion (19%) and intestinal ischemia (18%). At presentation, 27.8% of patients had a septic shock. The overall mortality rate was 5.13%, and 16.5% of patients required admission to Intensive Care Unit.

Microbiological samples were collected from 3,208 (70.8%) patients; 48.8% of intrabdominal samples resulted positive. Not surprisingly, the major pathogen involved in IAIs was E. coli (45.6%). Remarkably, in 29% of the cases microbiological samples were not collected.

During hospital stay, an empiric antimicrobial therapy was administered in 78.4% of patients. Amoxicillin/clavulanate was the most common antibiotic used (e.g., in 30.1% appendicitis, 30.5% of cholecystitis, and 55% small bowel perforation), followed by piperacillin/tazobactam (e.g., in 13.3% colonic perforation and diverticulitis, 22.6% cholecystitis, 28.6% pancreatitis). Empiric antifungal therapy was administered in 2.6% of patients with no sign of sepsis, 3.1% of patients with clinical sign of sepsis and 4.1% of patients with septic shock. Azoles were the most used antifungals in patients that received empiric antifungal therapy.

The authors concluded that antibiotic stewardship programs and correct antimicrobial and antifungal prescription campaigns are needed to further improve the appropriateness of drug usage and reduce the burden of AMR. This will contribute to better care and treatment for the next generations.

Reference

Coccolini F, Brogi E, Ceresoli M, et al. Epidemiological analysis of intra-abdominal infections in Italy from the Italian register of complicated intra-abdominal infections—the IRIS study: a prospective observational nationwide study. World J Emerg Surg. 2025;20:22.

Infection prevention and management in surgery: a global declaration

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

In a paper recently published in the World Journal of Emergency Surgery, seven surgical societies around the world shared an important declaration.

The authors – expert physicians representing the societies involved in this alliance – highlighted the threat posed by antimicrobial resistance (AMR), and the importance to prevent and manage infections appropriately across the surgical pathway.

The Global Alliance for Infections in Surgery (GAIS), the World Society of Emergency Surgery (WSES), the Surgical Infection Society (SIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), the American Association for the Surgery of Trauma (AAST), and the Panamerican Trauma Society (PTS) participated in the realization of this document.

The goal was to raise awareness among surgeons about AMR by focusing on the importance of actively participating in this challenge.

Surgeons really play a pivotal role in prevention and management of infections in their daily practice. Indeed, they are primarily responsible for preventing hospital-acquired infections, particularly surgical site infections. Moreover, they are prescribers of antibiotics, both for prophylaxis and therapy.

Nevertheless, among them adequate infection prevention and control (IPC) measures, and appropriate antibiotic prescribing practices are often disregarded. Why?

In healthcare facilities around the world, cultural, contextual, and behavioural determinants can influence surgeons’ clinical practice. Furthermore, other factors – such as the fear of clinical failure, time pressure, or organizational contexts – can limit their adherence to IPC procedures and antibiotic prescribing practices.

According to the authors, surgeons in hospital settings should be aware of their role and responsibility, and follow the fundamental principles for correct infection prevention and management across the surgical pathway.

***Fundamental principles for correct infect*****ion prevention and management across the surgical pathway**
*[Adapted from Figure 1 in Ref. 1].*

Changing clinical behaviour is extremely challenging.

A collaborative and multidisciplinary approach is paramount to optimize individual patients’ outcomes and overall healthcare delivery. Each healthcare provider of the team has to participate, and be responsible for its own contribution to patient care.

The authors concluded calling all surgeons around the world to take part in this global cause, by pledging support for this declaration, and accepting responsibility for maintaining the effectiveness of current and future antibiotics.

Reference

Sartelli M, Coccolini F, Ansaloni L, Biffl WL, Blake DP, Boermeester MA, Coimbra R, Evans HL, Ferrada P, Gkiokas G, et al. Declaration on infection prevention and management in global surgery. World J Emerg Surg. 2023 Dec 6;18(1):56.