Intra-abdominal infections (IAIs) are the most common cause of morbidity and mortality in surgical emergency patients. Early appropriate antimicrobial therapy is challenging because of the emerging antimicrobial resistance (AMR) leading to prolonged hospitalization and increased mortality, morbidity and healthcare costs. The article aimed to review epidemiology, etiology, resistance patterns and current antimicrobial therapy for IAIs in five Gulf countries.
Literature search was conducted for published articles from five Gulf countries (United Arab Emirates, Bahrain, Qatar, Oman and Kuwait) between January 2011 - September 2021 using “PubMed” and “Google Scholar”. Retrospective or prospective research studies conducted on adult/paediatric patients or meta-analyses of such studies in English language only were included.
From 69 screened studies, 18 met the inclusion criteria. Mean age of IAIs patients ranged between 29.6 - 53.2 years with male predominance (52.9 – 95.6%) noted across all clinical entities of IAIs.
Among IAIs patients, 61% were appendicitis, peritonitis (55% with single episode and 45% with multiple episodes), intra-abdominal abscess/pelvic abscess formation (46.4%), perforated duodenal ulcers (20.0%), bowel injury (57.5% for small bowel, 33.1% for colon, and 9.4% for combined small and large bowel), diverticulitis (3%) and small bowel perforation (1%).
Positive cultures were reported in 46.26% with liver abscess, 62.2% with peritonitis, and 3.32% with patients who underwent appendectomies. The common causative pathogens differed based on the site of infection. The most common cultured bacteria in peritonitis were Staphylococcus epidermidis (21%), Pseudomonas aeruginosa (14%) and extended spectrum beta-lactamase producers (ESBLs 3%). In Peritonitis patients undergoing peritoneal dialysis, Staphylococcus was the main causative pathogen (14.9%) followed by Streptococcus (13.2%).
Common pathogens isolated from blood culture of pyogenic liver abscess were Klebsiella pneumoniae (38%), Streptococcus melleri (11%), Escherichia coli (4%), Prevotella bivia and Enterococcus bovis (2%).
For surgical site infections following appendectomies, ESBL Escherichia coli represented 60%, Pseudomonas aeruginosa (20%) and Escherichia coli (non-ESBL), Enterococcus faecalis, Klebsiella pneumoniae (ESBL) were reported to be 5% each.
For pyogenic liver abscess, the mean duration of hospitalization was 13.6 ± 8.1 days, and the mean duration of antibiotic therapy was 34.7 ± 40.6 days. A mean length of stay of 6.42 days was reported with complicated appendicitis versus 3.82 days with non-complicated appendicitis. Higher in-hospital mortality in patients infected with multi drug resistant (MDR) bacteria as compared to those infected with other bacterial isolates (16.6% vs. 4.9%). Prolonged antibiotic usage was reported in patients who refused invasive procedures and received solely intravenous antibiotics for 14 days followed by 4 weeks of oral antibiotics.
Commonly prescribed antibiotics included ceftazidime, vancomycin, cefepime, meropenem, piperacillin/tazobactam, tigecycline and metronidazole. Inappropriate use of empiric piperacillin-tazobactam for peritonitis was reported.
IAIs are heterogenous set that poses significant management challenge. A call for attention to generate more reliable regional epidemiological studies on IAIs in adults and paediatrics which would provide a strong foundation for better understanding and management. Enhanced surveillance is crucial to monitor evolving AMR in IAIs and support stratified management approach. Antimicrobial stewardship efforts focused on IAIs are recommended to guide appropriate antibiotic usage.