Role of amikacin in the management of intra-abdominal sepsis.

Controversy has developed regarding the antibiotic management of intra-abdominal sepsis because of the recent availability of the third-generation cephalosporins and ureidopenicillins as alternatives to traditional combination therapy (aminoglycosides plus clindamycin). Most observers now acknowledge the need to provide anti-anaerobic as well as anti-aerobic gram-negative drug coverage. Although most of the newer agents do provide such broad-spectrum coverage, doubt remains regarding their efficacy because of flaws in comparative study design and the observation that resistance to the newer agents, which may even extend to the aminoglycosides, can emerge in individual patients during single courses of antibiotic therapy. Indeed, such resistance is most likely to occur during the treatment of seriously ill, immunodepressed patients who have undergone multiple reoperation for persistent or recurrent intra-abdominal sepsis--the precise group for which the new drugs were most desired as less toxic alternatives to the aminoglycosides. On the basis of such observations, combination therapy with the aminoglycosides, appears to remain the most logical choice. In the setting of nosocomial sepsis and pathogen resistance to other aminoglycosides, amikacin may be especially effective. Recent surveillance data indicate that the use of amikacin under such circumstances not only may provide effective antibiotic therapy, but also may actually reduce the level of microbial resistance to the other aminoglycosides. Past concern regarding the development of resistance to amikacin has probably been excessive and should not deter the use of this agent under appropriate clinical circumstances.