Begin resuscitation and antibiotics immediately when clinically significant leakage is suspected.
For stable community acquired postoperative intra abdominal infection without major resistant organism risk:
Ceftriaxone 2 g IV every 24 hours plus metronidazole 500 mg IV every 12 hours.
For severe sepsis, healthcare associated infection or significant resistant organism risk:
Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, adjusted for renal function.
A clinically stable patient with a small contained leak and no uncontrolled sepsis may be managed with bowel rest, antibiotics and close observation.
A well formed collection larger than approximately 3 cm is usually better managed with image guided drainage when technically accessible.
Operate for:
The operative objective is source control, not obligatory preservation or destruction of the anastomosis.
For an inaccessible low pelvic anastomosis surrounded by severe inflammation, washout, adequate drainage and proximal diversion may be safer than attempting difficult takedown.
A grossly disrupted or ischaemic anastomosis usually requires resection. Options include end stoma formation or reanastomosis with proximal diversion in a stable patient with healthy tissue.
After adequate source control, antimicrobial treatment should generally not exceed 4 days unless infection remains uncontrolled.
Persistent sepsis after apparently adequate treatment should trigger repeat source control assessment, not repeated extension of antibiotics.
