CASE LEARNING OBJECTIVES
Recognize the clinical presentation of a secondary intra-abdominal infection involving abscess
Identify the microorganisms typically involved in secondary intra-abdominal infections
Develop an appropriate treatment and monitoring plan for a secondary intra-abdominal infection on the basis of specific patient characteristics
Recommend the most appropriate drug and nondrug interventions to treat a secondary intra-abdominal infection
"I feel sick. My stomach hurts, especially right by my belly button. I have been running a fever for two days."
History of Present Illness
John Romans is a 34-year-old male who presents to the emergency department complaining of acute onset of severe abdominal pain, localized in the periumbilical region. The patient states that his persistent fever and a localized region of pain in his abdomen are new symptoms for him. His oral intake has decreased over the past week due to the pain. He has a past medical history significant for Crohn's disease, which was diagnosed 15 years ago. Currently, he receives infliximab infusions for his Crohn's disease. Methotrexate was prescribed in the past, but was not tolerated. In the past, intermittent high-dose corticosteroid tapers have been used for disease exacerbations with success. His last flare was1 month ago. Past surgical history includes a colostomy performed 12 years ago with no subsequent complications.
Crohn's disease (ileocolonic) diagnosed 15 years ago
Colostomy placement 12 years ago
Father died at age 36 from colon cancer. Paternal grandmother suffers from osteoporosis.
Works for a local nonprofit organization. No recent travel history outside the United States.
(−) Alcohol; (−) tobacco or illicit drug use
Allergies/Intolerances/Adverse Drug Events
No known medication allergies
Infliximab 760 mg IV q 8 wk
Malaise and fever for a couple of days despite use of acetaminophen; abdomen tender right of umbilicus with palpable mass that has developed over past few days; abdomen pain increases with eating; (−) significant weight loss, but states that he has lost a couple of pounds this past week; (−) hematochezia; patient reports increase in colostomy output during last week; no history of fistula or abscess formation.
Ill-appearing, diaphoretic Caucasian male in moderate acute distress
BP 108/43 mm Hg, P 101, RR 22, T 39.1°C