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.

Optimizing surgical antibiotic prophylaxis in the era of antimicrobial resistance: a position paper

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

Antimicrobial resistance (AMR) represents a serious threat to global health because antibiotics are losing effectiveness in both prevention and treatment of infections. The rising incidence of multidrug-resistant organisms (MDROs) challenges the efficacy of conventional surgical antibiotic prophylaxis (SAP) regimens.

Addressing this issue requires a re-examination of perioperative protocols, with attention to individual patient risk factors for MDRO colonization. Therefore, a targeted SAP approach should be considered when MDROs represent a significant surgical site infection risk. Thus far, limited evidence provides guidance on SAP selection in high-risk patients.

For these reasons, a position paper has been recently publishedin Pathogens by the Italian Multidisciplinary Society for the Prevention of Healthcare-Associated Infections (SIMPIOS). Following the best scientific evidence from PubMed and EMBASE Library a multidisciplinary working group produced 15 recommendation statements to optimize SAP in a context of AMR. They were graded according to the GRADE hierarchy of evidence. Using a Delphi approach, statements reaching ≥80% agreement were approved as strong recommendations.

This position paper is structured in three sections.

The first one widely reviewed the core principles for appropriate SAP. Then, the second section examined screening, decolonization, and targeted SAP in patients colonized with MDROs focusing separately on Gram-positive bacteria (methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant enterococci [VRE]), and Gram-negative bacteria (extended-spectrum beta-lactamase [ESBL]-producing and carbapenem-resistant Enterobacterales [CRE]).

The third section discussed the barriers to changing surgeons’ prescribing behaviours, focusing on surgeons’ awareness and dynamics within surgical teams that influence antibiotic prescribing practices. To track adherence and improvement in SAP, the authors listed the key performance indicators, and suggested a checklist, too.

Finally, they summarized all the 15 recommendation statements expressed by the multidisciplinary working group in order to provide practical guidance for optimising SAP in the context of an AMR era.

The authors concluded that in the AMR era the goal is to ensure that SAP remains effective in preventing infections while minimizing unnecessary antibiotic exposure. This can be achieved balancing patient safety with stewardship principles, tailoring SAP to epidemiological risk, and promoting a culture of shared responsibility across the surgical pathway.

Reference

Sartelli M, Labricciosa FM, Casini B, et al. Optimizing Surgical Antibiotic Prophylaxis in the Era of Antimicrobial Resistance: A Position Paper from the Italian Multidisciplinary Society for the Prevention of Healthcare-Associated Infections (SIMPIOS). Pathogens. 2025;14(10):1031.

Antimicrobial management of intra-abdominal infections: an Italian multidisciplinary Consensus Conference

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

In a paper recently published in the World Journal of Emergency Surgery, an Italian multidisciplinary group of healthcare professionals promoted a Consensus Conference on the antimicrobial management of intra-abdominal infections (IAIs).

IAIs are common surgical emergencies, representing an important cause of morbidity and mortality across global hospital settings. The cornerstones of IAIs management include timely diagnosis, adequate source control, early and appropriate antimicrobial therapy, and quick physiological stabilization through intravenous fluid therapy and vasopressor agents, especially in critically ill patients.

Optimizing antimicrobial therapy is of utmost importance to improve treatment effectiveness, increase patient safety, minimize the risk of selecting antimicrobial resistant microorganisms, and reduce the risk of opportunistic infections, such as Clostridioides difficile.

The Consensus Conference was promoted by the Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use which included diverse healthcare professionals: not only surgeons, but also infectious disease specialists, microbiologists, clinical pharmacologists, hospital pharmacists, emergency medicine specialists, intensivists, radiologists, and public health specialists.

After focusing on the general principles of diagnosis and treatment of IAIs, a list of relevant clinical questions was constructed to investigate the topic. Concerning the antimicrobial management of IAIs, basic subjects were faced, such as the optimal timing to start an antibiotic therapy, its reassessment based on the results of microbiological culture and susceptibility testing, its optimal duration, daily doses and modality of administration, without forgetting to discuss antifungal treatment, as well.

Following the best scientific evidence from PubMed, EMBASE Library and experts’ opinions, the panel produced 23 recommendation statements for the antimicrobial therapy of IAIs. They were planned and graded according to the GRADE hierarchy of evidence. Using a Delphi approach, a consensus was reached for each statement.

In the last section of the paper, 8 clinical diagnostic-therapeutic pathways for the most common IAIs were presented. The document was endorsed by the Italian Society of Surgery.

The authors concluded that an effective antimicrobial strategy for managing IAIs requires a correct balance between two elements: optimizing empiric therapy to improve clinical outcomes, and curbing excessive antimicrobial use to mitigate the emergence of multidrug-resistant strains.

Reference

Sartelli M, Tascini C, Coccolini F, Dellai F, Ansaloni L, Antonelli M, et al. Management of intra-abdominal infections: recommendations by the Italian council for the optimization of antimicrobial use. World J Emerg Surg. 2024 Jun 8;19(1):23.