It’s postoperative day four after surgery for a perforated colon. The source appears controlled, but the patient is still intubated, the white count is eighteen, and nobody feels comfortable stopping piperacillin–tazobactam. Is four days really enough? Does the ICU buy another four—or is it time to ask what we’re missing?

Join Drs. Rushabh Dev, Skye Shultz, Kelly Ray, Desra Fletcher, and Brycen Ratcliffe from the Emergency General Surgery team in Tiger Country at Mizzou as they revisit STOP-IT and examine what more than a decade of evidence has added to the management of complicated intra-abdominal infection.

In this EGS Journal Review, the team appraises the landmark trial, explores its subgroup analyses and limitations, and puts contemporary SIS, IDSA, AAST, and Surviving Sepsis guidance into context. The discussion moves from source control and antibiotic duration to resistant organisms, cultures, de-escalation, ICU dosing, and the role of procalcitonin.

For most complicated intra-abdominal infections, approximately four days after adequate source control remains the default. Persistent illness should prompt a search for failed source control, ineffective therapy, or another diagnosis before simply extending the stop date.

Hosts

Dr. Rushabh Dev, MD, FACS – Moderator and Acute Care Surgeon, University of Missouri
Dr. Skye Shultz – Surgical Critical Care Fellow, University of Missouri
Dr. Kelly Ray – General Surgery Resident; STOP-IT appraisal and antimicrobial selection
Dr. Desra Fletcher – General Surgery Resident, University of Missouri; post-STOP-IT evidence and implementation
Dr. Brycen Ratcliffe – General Surgery Resident; society guidance and microbiology

Learning Objectives

By the end of this episode, listeners should be able to:
· Describe the design, principal results, strengths, and limitations of STOP-IT, including why adequate source control is essential to applying its findings.
· Apply short-course therapy after adequate operative or percutaneous source control and explain why sepsis alone, obesity, or diabetes does not automatically require a longer course.
· Distinguish the four-day default from the weaker SIS recommendation supporting up to eight days in selected critically ill patients after adequate source control.
· Recognize persistent or worsening illness that warrants reassessment of source control, drain function, microbiology, drug exposure, or alternative diagnoses.
· Differentiate the treatment scope of SIS guidance from the diagnostic and microbiology focus of IDSA 2024, the AAST surgical ICU consensus, and broader sepsis and antimicrobial-resistance guidance.
· Select and de-escalate antimicrobials using infection setting, resistance risk, cultures, local susceptibility data, and patient-specific dosing considerations.
· Explain the limited adjunctive role of procalcitonin in antibiotic discontinuation when duration remains uncertain, including the implications of ADAPT-Sepsis.

References

1. Sawyer RG, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015;372:1996–2005. STOP-IT. Article / guideline

2. Huston JM, et al. The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update. Surg Infect. 2024;25:419–435. Article / guideline

3. Rattan R, et al. Patients with complicated intra-abdominal infection presenting with sepsis do not require longer duration of antimicrobial therapy. J Am Coll Surg. 2016;222:440–446. Article / guideline

4. Rattan R, et al. Percutaneously drained intra-abdominal infections do not require longer duration of antimicrobial therapy. J Trauma Acute Care Surg. 2016;81:108–113. Article / guideline

5. Montravers P, et al. Short-course antibiotic therapy for critically ill patients treated for postoperative intra-abdominal infection: the DURAPOP randomized clinical trial. Intensive Care Med. 2018;44:300–310. Article / guideline

6. IDSA. 2024 Guideline Update on Complicated Intra-Abdominal Infections: Risk Assessment, Diagnostic Imaging, and Microbiological Evaluation. Article / guideline

7. Nohra E, et al. Fever and infections in surgical intensive care: an AAST Critical Care Committee clinical consensus document. Trauma Surg Acute Care Open. 2024;9:e001303. Article / guideline

8. IDSA. 2026 Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative Infections. Article / guideline

9. Prescott HC, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Crit Care Med. 2026. Article / guideline

10. Dark P, et al. Biomarker-guided antibiotic duration for hospitalized patients with suspected sepsis: the ADAPT-Sepsis randomized clinical trial. JAMA. 2025;333:682–693. Article / guideline

After adequate source control, most complicated intra-abdominal infections need approximately four days of antibiotics. If the patient is not improving, reassess the source and the treatment—not just the calendar.

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Journal Review in Emergency General Surgery: STOP-IT - What a Decade of Data Has Taught Us

Behind The Knife: The Surgery Podcast

Journal Review in Emergency General Surgery: STOP-IT - What a Decade of Data Has Taught Us