Management of Infections in Patients Receiving Epidural Steroid Injections

Contraindications and Risks

Epidural steroid injection is contraindicated in patients with active peritoneal infection and sigmoid colon abscess due to the high risk of spreading infection to the epidural space and potential catastrophic neurological complications 1
The presence of an active infection elsewhere in the body presents a significant risk factor for performing invasive procedures like epidural injections due to potential hematogenous spread of bacteria to the epidural space during needle insertion 1
Introducing a needle into the epidural space with distant infection creates a risk of seeding infection, which could lead to epidural abscess formation and potential paralysis 1, 2

For sigmoid colon abscess >3 cm, percutaneous drainage with early empiric antibiotic therapy is recommended by the World Society of Emergency Surgery (WSES) 1
For smaller abscesses (<3 cm), intravenous antibiotics with close monitoring are recommended by the WSES 1
Intra-abdominal abscesses require adequate source control before any elective procedures, according to the WSES and Infectious Diseases Society of America (IDSA) guidelines 2
Surgical intervention is necessary for source control, with guidelines from the IDSA and World Journal of Emergency Surgery supporting immediate surgical intervention for diffuse peritonitis 3, 2, 4

Prompt antimicrobial therapy against Gram-negative aerobic/facultative bacilli, Gram-positive streptococci, and obligate anaerobic bacilli is recommended by the WSES 1
Antimicrobial therapy should be completed and infection fully resolved before considering immunosuppressive interventions, according to the WSES and IDSA guidelines 1, 2
First-line therapy options include:
Alternative first-line therapy for beta-lactam allergy includes Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h 5
Third-generation cephalosporins (e.g., cefotaxime 2 g every 8 hours) can also be used as first-line therapy, according to the World Journal of Emergency Surgery and the IDSA 6, 2
The recommended duration of therapy is:

Clinical improvement, normalization of inflammatory markers, and follow-up imaging to confirm abscess resolution are necessary before considering epidural injection 1
Patients with peritoneal infection require close monitoring even when clinically stable, as their condition can rapidly deteriorate, according to the IDSA guidelines 2
Epidural injection should only be considered after complete resolution of infection, completion of full antibiotic course, and no signs of systemic infection for at least 2-4 weeks 1, 2
Monitor for resolution of peritonitis through clinical improvement and normalization of inflammatory markers, as recommended by the IDSA and World Journal of Emergency Surgery 2, 5
If no improvement after 2 days of antibiotic treatment, consider antibiotic failure, resistant organisms, or secondary peritonitis, according to the European Association for the Study of the Liver and the IDSA 8, 2
Carefully monitor for complications such as intra-abdominal abscesses, sepsis, and organ dysfunction, with guidelines from the IDSA emphasizing the importance of vigilant monitoring 2

Patients with diffuse peritonitis should undergo emergency surgical procedure as soon as possible, even while resuscitation continues, as recommended by the IDSA and World Journal of Emergency Surgery 2, 4
An appropriate source control procedure to drain infected foci, control ongoing contamination, and restore anatomical function is recommended for nearly all patients, with guidelines from the IDSA and World Journal of Emergency Surgery supporting this approach 2, 4
The specific surgical approach depends on the cause of peritonitis, including:
Where feasible, percutaneous drainage of abscesses and well-localized fluid collections is preferable to surgical drainage, as recommended by the IDSA and World Journal of Emergency Surgery 2, 4
On-demand relaparotomy is recommended over planned relaparotomy for severe peritonitis, with guidelines from the World Journal of Emergency Surgery supporting this approach 4

Antifungal therapy is not routinely recommended for community-acquired peritonitis, but should be considered for hospital-acquired infections and in critically ill or severely immunocompromised patients, as suggested by the World Journal of Emergency Surgery and the IDSA 9, 2
Consider antifungal therapy in hospital-acquired infections and critically ill or immunocompromised patients, with guidelines from the World Journal of Emergency Surgery and the IDSA supporting this approach 9, 2