Which antibiotics are used as treatment for intestinal perforation?

Updated: Jul 24, 2020
  • Author: Samy A Azer, MD, PhD, MPH; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

Metronidazole is typically used in combination with an aminoglycoside to provide broad gram-negative and anaerobic coverage. It is reduced to a product that interacts with deoxyribonucleic acid (DNA) to cause a loss of helical DNA structure and strand breakage, resulting in inhibition of protein synthesis and cell death in susceptible organisms. Adult dosing is 7.5 mg/kg IV before surgery. Pediatric dosing is 15-30 mg/kg/day IV divided bid/tid for 7 days. Metronidazole is a pregnancy category B drug.

Gentamicin is an aminoglycoside antibiotic with gram-negative coverage. It is used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Although it is not the drug of choice, it should be considered if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.

Gentamicin dosing regimens are numerous; the dosage is adjusted on the basis of creatinine clearance (CrCl) and changes in volume of distribution. It may be given IV or intramuscularly (IM). In adults, the loading dose before surgery is 2 mg/kg IV; thereafter, the dosage is 3-5 mg/kg/day divided tid/qid. In infants, the dosage is 7.5 mg/kg/day IV divided tid. In children, the dosage is 6-7.5 mg/kg/day IV divided tid. Gentamicin is a pregnancy category C drug.

Cefotetan is a second-generation cephalosporin that inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins. It inhibits the final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death. Adult dosing is 2 g IV once before surgery. In children younger than 3 months, dosing is not established. In those older than 3 months, dosing is 30-40 mg/kg IV once before surgery. Cefotetan is a pregnancy category B drug.

Cefoxitin is also a second-generation cephalosporin that inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins. It inhibits the final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death. Adult dosing is 2 g IV once before surgery, followed by 4 doses of 2 g IV q4-6hr. In children younger than 3 months, dosing is not established. In those older than 3 months, dosing is 30-40 mg/kg IV before surgery, followed by 3 doses of 2 g IV q4-6hr for 24 hr. Cefoxitin is a pregnancy category B drug.

Ertapenem is indicated for complicated intra-abdominal infections in adults and children aged 3 years or older. It is a carbapenem that inhibits cell-wall synthesis by binding to penicillin-binding proteins. It is resistant to most beta-lactamases. Dosing in adults and adolescents is 1 g IV or IM once daily for 5-14 days. The dosage for children aged 3-12 years is 15 mg/kg IV or IM q12hr for 5-14 days.

Eravacycline is a synthetic fluorocycline antibiotic belonging to the tetracycline class. It disrupts bacterial protein synthesis by binding the 30S ribosomal subunit, thus preventing incorporation of amino acid residues into elongating peptide chains. It is indicated in adults for treatment of complicated intra-abdominal infections caused by the following susceptible bacteria:

  • E coli
  • Klebsiella pneumoniae
  • Citrobacter freundii
  • Enterobacter cloacae
  • Klebsiella oxytoca
  • Enterococcus faecalis
  • Enterococcus faecium
  • Staphylococcus aureus
  • Streptococcus anginosus group
  • Clostridium perfringens
  • Bacteroides species
  • Parabacteroides distasonis

Dosing is 1 mg/kg IV every 12 hours for 4-14 days. Dosage modifications are required in patients with severe hepatic impairment or if coadministered with strong CYP3A inducers. Approval for complicated intra-abdominal infections was based on results from the IGNITE-1 clinical trial (N = 541), which demonstrated that eravacycline was noninferior to ertapenem. [20]


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