- The Bioidentical Hormone Debate:
Are Bioidentical Hormones (Estradiol, Estriol, and Progesterone) Safer or More Efficacious than Commonly Used Synthetic Versions in Hormone Replacement Therapy? - Prevention, Screening, and Management of Osteoporosis:
An Overview of the Current Strategies - Inflammatory Arthritis:
An Overview for Primary Care Physicians
Keywords: complicated intra-abdominal infections; appendicitis; diverticulitis; antimicrobials; fluoroquinolones
Patients who present with severe abdominal pain may be a diagnostic challenge for the evaluating physician. Many conditions, some of which may be life-threatening, can cause severe abdominal pain. Because the history and physical examination of abdominal pain are often nondiagnostic, additional testing or serial examinations are sometimes needed. Patients whose diagnosis is unclear should be admitted for observation and work-up. Appendicitis and diverticulitis are 2 serious conditions that require immediate diagnoses to avoid poor clinical outcomes. This article compares the presentations and treatments of these disorders.
A literature search was conducted to identify recent clinical trials and consensus guidelines addressing the diagnosis and management of complicated intra-abdominal infections. It focused on studies and guidelines that specifically addressed appendicitis and diverticulitis, when possible. Level of evidence 1 to 3 criteria was applied to the selection of articles included in this review.
Many crucial issues, such as age, should be considered in a patient with severe abdominal pain (Table 1).1 Although appendicitis and diverticulitis can occur at any age, the ages at which most patients present with these diseases are different. In the United States and the European Union, appendicitis most commonly occurs in patients aged 10 to 30 years.2 Presentation of diverticulitis, however, occurs at a mean age of 59 years, with the disease presenting at a younger age in males (although prevalence among men and women is similar).3 Previous estimates of patients with diverticular disease aged < 40 years ranged from 2% to 5%,4-6 but more recent studies demonstrate an increase in incidence of diverticulitis in younger patients, possibly caused by increased obesity and low-fiber diets.7
Assessment of the character, duration, location, and status of abdominal pain is imperative. A detailed menstrual history should be obtained from all females of childbearing age. In general, pain associated with medical diseases tends to improve over time, whereas pain associated with surgical diseases becomes more severe.
Abdominal pain is one of the most common medical conditions that call for prompt diagnosis and treatment.8 Physical appearance may assist the evaluating physician with diagnosis. Patients with severe abdominal pain look ill and may appear diaphoretic or toxic. Patients with peritonitis are often found to be supine and motionless. Intermittent, writhing pain suggests an obstructing lesion of the biliary, gastrointestinal, or urinary tract. The location of the pain is also very useful (Figure 1).9 For example, pain in the left lower quadrant and left abdomen is more typical of diverticulitis, whereas pain in the right lower quadrant is more typical of appendicitis.
Severe abdominal pain may occur with normal or altered vital signs. Patients who suffer a perforated viscus will have tachycardia and will often be febrile. A rectal temperature should always be obtained. A pelvic examination is indicated in all female patients. Chest examination may reveal splinting, but auscultation of the lungs and heart will be unaffected. Abdominal examination will almost always be remarkable. The inguinal region should always be examined in the upright position to exclude an incarcerated hernia. Severe abdominal pain without an impressive abdominal examination may indicate mesenteric ischemia. Patients who have free perforation typically have guarding, rigidity, and a paucity of bowel sounds. High-pitched bowel sounds may be present over an area of obstruction.
The initial laboratory evaluation should include a complete blood count with differential and platelets, coagulation studies (prothrombin time, partial thromboplastin time), chemistry and liver function tests, and amylase and lipase. A urine specimen should be evaluated for bacteria, white blood cells (WBC), and red blood cells. Female patients of childbearing age should have a urine or serum pregnancy test. Elderly patients and patients with a history of coronary artery disease should have an electrocardiogram to rule out myocardial ischemia and to serve as a baseline in case anesthesia and surgical intervention are needed. A chest radiograph should be used to evaluate pneumonia in adult patients.
Although laboratory tests are similar for appendicitis and diverticulitis, particular laboratory findings suggest one disease rather than the other. These findings are discussed below. The typical elevation found in appendicitis is quite minor (WBC, 10.5–13.5).
Appendicitis is the most common surgical emergency; approximately 1.1 cases of appendicitis per 1000 people (~7% lifetime incidence of acute appendicitis) are seen annually.10 The most commonly affected ages are 10 to 30 years,11 69% of cases occurring in patients aged < 30 years.12 The lifetime risk of acute appendicitis is about 7% in women and 9% in men.13 Appendicitis is due to a closed-loop obstruction of the appendix caused by lymphoid hyperplasia or impacted fecal matter (fecalith). Obstruction of the appendix leads to bacterial overgrowth and an increase in intraluminal pressure, which blocks the venous blood flow and congests the appendix.14 The process can then lead to perforation.
The pain usually begins with vague abdominal discomfort occurring over 2 to 6 hours and becoming localized to the right lower quadrant. Pain is found in nearly 100% of patients, while the history of migrating abdominal pain is found in 50% of patients.15 The pain is exacerbated by movement of the abdomen. Patients often report anorexia, nausea, vomiting, and constipation. The physical examination typically reveals point and rebound tenderness, guarding, and rigidity. Temperature is elevated mildly (approximately 100°F) with mild leukocytosis. The WBC count is elevated (>10000 per mm3) in 80% of acute appendicitis cases.16
Three physical examination signs support the diagnosis of appendicitis: 1) Rovsing’s sign (pain in the right lower quadrant with moderate palpation of the left lower quadrant, 2) the psoas sign (pain with slow extension of the right thigh with the patient lying on the left side (Figure 2A),17 and 3) the obturator sign (pain with passive internal rotation of the flexed right thigh with the patient supine) (Figure 2B).17 Tenderness of the right lower quadrant on rectal examination also supports the diagnosis.
Despite technological advances, the diagnosis of appendicitis is still based primarily on the patient’s history and physical examination.18 When an experienced physician diagnoses appendicitis and this diagnosis is confirmed with confidence by surgical consultation, further confirmation by computed tomography (CT) is of limited value.19,20 Serial examinations required in some cases may lead to delay in diagnosis compared with a more rapid diagnosis achieved by CT scan. Computed tomography is an important tool that can reduce the incidence of negative laparoscopies in patients who present with atypical symptoms,21 and is most useful when clinical diagnosis is in doubt.22 Computed tomography is a very accurate and efficient diagnostic tool for clinicians practicing in a busy emergency department. Younger patients in whom appendicitis is strongly suspected may be triaged directly to surgery for appendectomy.
In elderly patients, the presentation of appendicitis is frequently atypical, characterized by high perforation rates, delay in treatment (often due to late presentation), and unfavorable outcomes, including a higher rate of appendiceal rupture. The death rate is also higher in older patients. These patients must be evaluated by an experienced surgeon within a narrow timeframe.23
Appendicitis is the most common acute surgical condition in pregnancy, occurring in approximately 1 in 1500 to 2000 pregnancies.24,25 The condition occurs most frequently during the first 2 trimesters. The pain of appendicitis is often localized to the right upper quadrant in pregnancy, as well as other unusual locations, because the position of the appendix shifts as the uterus enlarges. The risk of perforation is somewhat higher in pregnant patients because of delay in diagnosis. Perforation and peritonitis increase the risk of complications, including premature labor, abortion, and maternal mortality. Fetal mortality is > 10% in cases of perforating appendicitis.25-27 Pregnant women with appendicitis require antibiotics and immediate surgery. The use of tocolytic agents is controversial.25,26
Pain may be localized poorly in patients with a retrocecal appendix.
The diagnosis of acute appendicitis is based on clinical findings, but radiologic studies are very helpful.
Ultrasonography may be most helpful when the surgeon is unwilling to operate immediately. Ultrasound is approximately 85% sensitive and specific, with an overall accuracy of 85% for the diagnosis of acute appendicitis.28 Ultrasonographic findings include a noncompressible, immobile, blind-ended or ring structure > 6 mm with the appearance of a target.
Computed tomography scanning is important when the diagnosis is uncertain, particularly when nonsurgical alternative diagnoses, such as nonperforated diverticulitis or pancreatitis, are under consideration. Computed tomography has a sensitivity of 94% to 98%, specificity of 83% to 100%, and accuracy of 93% to 96% for diagnosing acute appendicitis and associated complications.29-31 Rectal contrast improves the accuracy of CT scanning in patients with suspected appendicitis.30,31 The negative appendectomy rate of 20% to 50% can be decreased to a range of 7% to 17% using CT.32 Computed tomography findings of appendicitis include distension of the appendix to > 6 mm, pericecal fat stranding, periappendiceal inflammatory changes, or visualization of an appendicolithiasis.
Obstruction of a diverticulum can lead to inflammation and pain that is pathophysiologically similar to appendicitis. Abdominal pain is the most common symptom, occurring in approximately 95% of cases (Table 2).1,33 Severe diverticulitis is complicated frequently by abscess or fistula formation or peritonitis. Mortality is high among patients with purulent or fecal peritonitis. The risk of free perforation, need for surgery, and postoperative death are greater in immunocompromised patients.
The incidence of diverticulitis ranges from 10% to 25% in patients with colonic diverticula, a condition known as diverticulosis.34 Colonic diverticula are herniations of colonic mucosa and submucosa that extend through the muscularis propria. They are small (0.5–1 cm in diameter) and occur in rows at sites of vascular penetration between the single mesenteric taenia and one of the antimesenteric teniae. Technically, colonic diverticula are pseudodiverticula because they do not involve all layers of the bowel wall. The majority of diverticula are in the sigmoid colon. Diverticulosis is related to a low-fiber diet. A diverticulum becomes inflamed as a result of obstruction by feces, hardened mucous, or a mucosal erosion. No published study has confirmed that diverticulitis is caused by seeds, nuts, or popcorn; some evidence suggests that eating nuts frequently may actually reduce the risk of developing inflammatory complications from diverticulosis.35
The frequency of diverticulosis increases with age. Diverticulosis occurs in approximately 5% of patients aged 30 to 39 years and in as many as 60% to 75% of patients aged ≥ 80 years.36-38 The condition is much more common in industrialized nations. Diverticulitis generally is considered to be a disease of older patients, although the number of patients with this condition aged ≤ 50 years appears to be increasing.7 Younger patients are more likely to be male.7
Computed tomography scanning of the abdomen and pelvis is the safest, most informative way to image suspected diverticular inflammation. Computed tomography scanning is also the most useful technique to evaluate diverticular abscess (Figure 3). The study should be completed with intravenous and oral contrast, although rectal contrast may be helpful. For patients in whom intravenous contrast is contraindicated, the procedure should be completed with oral contrast only.
For patients with suspected obstruction or diverticulitis, a limited single-contrast barium or diatrizoate enema study may also be performed, although it is not the preferred modality. Barium should not be used if either perforation or generalized peritonitis is a concern. However, the risk of free perforation or opening of a sealed perforation from instillation of contrast medium into the sigmoid colon is low. Ultrasound is not the preferred method to evaluate diverticulitis, but ultrasound findings include diverticula of variable echogenicity with pericolic inflammation.
Localized thickening of the bowel wall or inflammation of the adjacent pericolic fat (“fat stranding”) is strongly suggestive of diverticulitis. Typically, these findings are seen in an area of diverticulosis. Extraluminal air or fluid collections are sometimes seen together with diverticula. Other findings include extravasation of contrast medium outlining an abscess cavity, an intramural sinus tract, or a fistula. In patients with mild diverticulitis, the CT scan may look normal. In some cases of diverticulitis, small abscesses in the mesocolon or bowel wall may not be seen.
Colonoscopy is contraindicated in acute diverticulitis because of local infection and threatened perforation. It should never be performed in patients with marked abdominal tenderness. Colonoscopy may be performed safely 6 to 8 weeks after the infectious process subsides.
When diverticulitis is untreated in the early stages, it progresses and may lead to rupture of the colonic wall. The rupture may cause free perforation and peritonitis or a focal area of infection and abscess formation. In either case, the infection will be polymicrobial and will include Gram-positive, Gram-negative, and anaerobic bacteria.
Perforation is associated with a delay in diagnosis and with a mortality rate of 15% to ≥ 30%.39,40 Perforated diverticular disease is associated with the use of nonsteroidal anti-inflammatory drugs, corticosteroids, and opioid analgesics.41
Development of an abscess is a common complication in diverticulitis. Fistulae to adjacent organs and the skin may develop in the presence of an abscess. In men, the most common fistula is colovesicular. In women, the uterus is interposed between the colon and bladder, precluding fistula formation, so this complication is seen only after a hysterectomy. Colovaginal and colocutaneous fistulae are uncommon.
Right-sided diverticulitis is rare in western countries. Symptoms are similar to those of appendicitis, which may make the differential diagnosis difficult. In general, no difference exists in the treatment for right- and left-sided diverticulitis. When needed, resection of the inflamed colon with primary anastomosis is wise and can be performed laparoscopically by an experienced surgeon.
The treatment for appendicitis is surgical removal of the appendix. The procedure may be open or laparoscopic. Laparoscopic procedures reduce hospitalization, postoperative pain, and wound infection but require more operative time. Laparoscopic procedures are converted to open procedures in 10% of cases. Fluids should be replaced preoperatively. Prophylactic adjunctive antibiotics reduce the risk of wound infection and intra-abdominal abscess. In patients with symptoms consistent with appendicitis, the rate of finding a normal appendix at the time of surgery is 10% to 15%. In those cases, the normal appendix should be removed to eliminate the chance of similar symptoms prompting repeat attempted appendectomy. Interval appendectomy is controversial. Some authors suggest that interval (or staged) appendectomy is a safe and effective approach for patients with complicated appendicitis, such as an abscess or fistula, because it allows more thorough diagnostic evaluation, reduces operating time, and can reduce the chance of concomitant cecal resection.42,43 Yet other investigators have shown that interval appendectomy after initial use of nonoperative therapy is clearly not justified,44,45 and have suggested that this management approach poses risks for complications and is associated with considerably greater use of resources.46
Treatment of diverticulitis always involves antibiotics. More severe cases may require radiological drainage or surgical resection. A treatment algorithm is provided in Figure 4.47
Outpatient treatment of mild diverticulitis consists of a low-residue diet, broad-spectrum, well-absorbed oral antibiotics, and close observation. Patients who do not show improvement during the first 3 days should be admitted to the hospital.
The mainstays of medical therapy for severe diverticulitis are intravenous antibiotics and supportive care. Patients with severe diverticulitis should be observed closely for signs of peritonitis. Patients initially should receive intravenous fluids and glucose, but nothing orally. Their diet may be advanced slowly, beginning with clear liquids. A small pericolic abscess can be treated with antibiotics and conservative therapy alone. After clinical improvement, patients should undergo a follow-up CT scan to ensure resolution.
The formation of a diverticular abscess depends on the ability of the pericolic tissues to localize the spread of the inflammatory process. Percutaneous drainage in combination with antibiotics is the treatment of choice for small, simple, well-defined fluid collections. Multilocular collections, abscesses associated with enteric fistulae, and abscesses containing solid or semisolid material can limit the success of percutaneous drainage.48
Approximately 20% of patients with diverticulitis require surgical treatment. Surgical treatment of nonperforated, acute, complicated diverticulitis remains controversial.47 Morbidity and mortality do not depend on the operative procedure as much as the severity of disease, associated comorbid conditions, immune and nutritional status, and the presence of feculent or purulent peritonitis. An effort should be made to time surgical treatment so that it takes place during a quiescent period 8 to 10 weeks after the last attack. At that time, the patient should be considered for laparoscopic or laparoscopic-assisted surgery. About 25% of these procedures are converted to open procedures; the primary risk factor for conversion is a history of previous abdominal surgery.49 In nonperforated disease, the patient should be stabilized, abscesses drained percutaneously if possible, and the bowel prepared for exploration.47
Urgent surgery is indicated for large bowel obstruction secondary to diverticulitis. Although the obstruction usually is partial, it is associated with considerable morbidity and mortality. If the obstruction is high grade, the cecum is dilated to ≥ 10 cm, and tenderness is felt in the right lower quadrant, then expeditious surgery is indicated.
Emergency surgery is indicated in patients with evidence of severe perforated diverticulitis and patients who are deteriorating despite adequate medical therapy. Attempts should be made first to treat the patient with intravenous antibiotics and drainage of abdominal abscesses.
Emergency operations for diverticulitis are associated with a worse outcome than are elective surgeries.50 Thirty-day mortality is 3% in emergency operations compared with 1% for elective cases. The colostomy rate is higher than 50% in emergency cases compared with 15% in the elective setting.50
The long-term management of recurrent attacks of acute diverticulitis differs according to the age of the patient, comorbid conditions, and the number of attacks.51 Surgical resection after an initial attack of diverticulitis based solely on age is not recommended. Younger patients with multiple episodes of recurrent diverticulitis should be considered for elective resection of the diseased segment of colon. Data exist to support elective partial colon resection after 2 episodes and continued conservative management.52,53 Response to conservative therapy appears to decrease with each recurrence. Patients aged < 50 years who develop acute left colonic diverticulitis are more likely than older patients to have recurrences or complications when treated conservatively.54 Recurrences are not more severe than initial episodes. The most current research recommends that patients should have at least 3 episodes of diverticulitis before segmental colectomy.50,51,55 The mortality rate for elective surgery in patients younger than 50 is close to 0%.53
Appendicitis and diverticulitis require antibiotic therapy. Antibiotic therapy in appendicitis may be given for a short course in patients with uncomplicated infections, but longer-term therapy is required in those with complicated infections. The choice of antibiotic is crucial for patients with appendicitis or diverticulitis, who are frequently treated without the guidance of cultures. For this reason it is essential to understand the microbiology of intra-abdominal infections to make a prudent antibiotic choice.
Complicated intra-abdominal infections, such as those encountered in patients with appendicitis and diverticulitis, typically are polymicrobial and involve bacteria normally found in the gastrointestinal tract.56,57 Clinical laboratories usually isolate 1 or 2 species per sample, predominately aerobes;58,59 however, laboratories associated with clinical research isolate many more (5–10 species, predominately anaerobes),60,61 indicating that the number of different microorganisms is underestimated clinically.56
Escherichia coli is the most common organism isolated (≥ 50%).60-62 Less frequently isolated are Klebsiella, Pseudomonas, and Enterobacter.56 Streptococcus species, primarily viridans type, are the most common Gram-positive cocci isolated.61,62 Enterococcus species are more common in patients who have received prior antimicrobial therapy. Staphylococcus species are uncommon in intra-abdominal infections, found primarily in patients with tertiary peritonitis; methicillin resistance is common among the Staphylococcus species found in intra-abdominal infections.56
Bacteroides fragilis is the most common anaerobe encountered in intra-abdominal infections.63 Other frequently isolated anaerobes include Peptostreptococcus, Peptococcus, Eubacterium, Fusobacterium, and Clostridium species.56,60-63 Fungi are uncommon in patients with community-acquired infections but are encountered in patients with hospital-acquired infections. Candida albicans is the most frequently isolated species,64,65 but other Candida species are increasingly being cultured.56,66,67
Appropriate selection of antibiotic therapy is important for successful management of intra-abdominal infections.68 Various single and combination antibiotic therapies for treatment of complicated intra-abdominal infections have been recommended by the Infectious Diseases Society of America and the Surgical Infection Society.57,69 Empirical treatment includes antibiotics against Gram-negative bacilli and obligate anaerobes commonly seen in these infections. In patients with mild-to-moderate infections, guidelines recommend single agents, such as ampicillin/sulbactam, ticarcillin/clavulanate, ertapenem, and moxifloxacin, or combination therapy with cefazolin, cefuroxime, ciprofloxacin, or levofloxacin.56,57,69,70
For high-risk patients, antimicrobial treatment varies widely depending on each patient’s condition. Risk factors for treatment failure or death include a higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score, poor nutritional status, significant cardiovascular disease, and inadequate control of the source infection.57 Broader-spectrum antimicrobials are generally required in these patients because of frequent infection with resistant organisms. In patients with more severe infections or who are immunosuppressed, consideration of a broader spectrum of antimicrobial activity against facultative and aerobic Gram-negative organisms is appropriate.
Recommendations include meropenem, imipenem/cilastatin, piperacillin/tazobactam, or combination therapy with a third- or fourth-generation cephalosporin plus metronidazole, ciprofloxacin plus metronidazole, or aztreonam plus metronidazole.56,57,70 Nosocomial intra-abdominal infections are usually caused by more resistant bacteria, such as Pseudomonas aeruginosa and Enterococcus species.57 It is suggested that local nosocomial flora be considered for these patients and that more resistant organisms are frequently encountered in these health care-associated intra-abdominal infections. However, aminoglycosides are suggested for first-line treatment in these patients and a combination of an aminoglycoside, a fluoroquinolone, or a carbapenem plus vancomycin is recommended for postoperative infections.57
Two fluoroquinolones, ciprofloxacin and moxifloxacin, are approved by the Food and Drug Administration (FDA) for the treatment of complicated intra-abdominal infections.71,72 Fluoroquinolones demonstrate broad-spectrum antimicrobial activities against Gram-negative aerobes and most β-lactam-susceptible Gram-positive staphylococci and streptococci.70 Moxifloxacin also provides coverage against anaerobic pathogens in complicated intra-abdominal infections, is the only FDA-approved fluoroquinolone for monotherapy in the treatment of complicated intra-abdominal infections, and is available in oral and intravenous forms at the same dosage.71 Moxifloxacin monotherapy is recommended for mild-to-moderate complicated intra-abdominal infections, as are ciprofloxacin and levofloxacin in combination with metronidazole.70 Ciprofloxacin in combination with metronidazole is also recommended for complicated intra-abdominal infections with high severity of infection.70 Fluoroquinolones provide wide distribution and good tissue concentrations in intraperitoneal organs and adequate coverage against aerobic and anaerobic pathogens in complicated intra-abdominal infections.70,73-76 In a phase 3 randomized controlled trial, intravenous and oral moxifloxacin once daily was shown to be as effective and well tolerated as standard intravenous piperacillin-tazobactam/oral amoxicillin-clavulanate regimen dosed multiple times daily.77
Guidelines for intra-abdominal infections from the Infectious Diseases Society of America and the Surgical Infection Society recommend limiting therapy to 5 to 7 days for most patients with intra-abdominal infections.57,69,78 Patients with complicated infections typically are treated for 5 to 14 days.56 However, if source control is adequate, prolonged therapy may not be needed.79 In patients with complicated diverticulitis, long-term antibiotic therapy is given in conjunction with radiologic drainage or surgical intervention. For patients with persistent signs of infection, prolongation of antimicrobial therapy does not avoid treatment failure and additional diagnostic studies to locate the source of infection are recommended.56 Table 3 lists the recommended antibiotic therapy for patients with diverticulitis.
Peritonitis indicates inflammation of the peritoneal cavity. Diverticulitis and appendicitis can be associated with peritonitis, which represents a very serious consequence of both diseases. The majority of clinically significant cases are caused by bacteria.
Peritonitis associated with diverticulitis or appendicitis can be localized or diffuse. Peritonitis is polymicrobial, with E coli, Klebsiella, Proteus, Enterobacter, and anaerobes, particularly B fragilis, Clostridium, and Enterococcus, predominating. Pseudomonas is isolated frequently. The flora depends on the site of perforation. Perforation of the colon, for example, leads to > 400 different species of bacteria invading the peritoneal cavity, with only a few species leading to severe infection. Gastrointestinal leakage into the peritoneal cavity can rapidly lead to septic syndrome.
Broad-spectrum coverage is needed for peritonitis. Antibiotics must have activity against E coli and B fragilis. Primary choices are second- and third-generation cephalosporins, such as cefoxitin, cefotaxime, ceftizoxime, or cefotetan; broad-spectrum penicillins, such as ampicillin/sulbactam; or newer agents, such as meropenem. Other options include the broad-spectrum fluoroquinolones. Older regimens using triple antibiotic combinations, such as ampicillin, an aminoglycoside, and metronidazole, are obsolete. The duration of therapy should be guided by the surgical and radiologic findings, including the need for interventional drainage and clinical status.
Diverticulitis and appendicitis are similar in many ways, yet different in others. The pathophysiology of these diseases is very similar in that both are caused by obstruction of a blind pouch that leads to inflammation of the structure and surrounding tissue. Because of the conformation of the appendiceal structure, free perforation is more likely in appendicitis. In diverticulitis, microperforation is almost always part of the disease, whereas in appendicitis, perforation is a more defined and dramatic event. Acute diverticulitis in the early stages is treated with antibiotics alone, whereas acute appendicitis is always treated with antibiotics and surgical resection.
Many equivalent options are available to treat the complicated intra-abdominal infections encountered in appendicitis and diverticulitis. The choice of antimicrobial therapy is guided by the type of infection, the severity of infection, the patient’s condition and prior exposure to antibiotics, local resistance and susceptibility patterns, and cost. The optimal duration of therapy remains undefined, although 5 to 14 days typically is required for more complicated infections. To reduce the development of resistance, antimicrobial therapy should be stopped once clinical signs of infection resolve. Prolonged therapy generally does not benefit patients with persistent infections who do not respond to more conservative therapy; further diagnostic studies and radiological and/or surgical intervention should be considered.
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1Division of Gastroenterology, School of Medicine, University of California Los Angeles, Los Angeles, CA
Correspondence: Mitchell J. Spirt, MD, Division of Gastroenterology, School of Medicine, University of California Los Angeles, Los Angeles, CA 90067.
Tel: 310-551-0082,
Fax: 310-286-0616,
E-mail: mjs5856@pol.net