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To assess risk factors for 28-day mortality and cost implications in intensive care unit (ICU) patients with complicated intra-abdominal infections (cIAIs).Single-center retrospective cohort study of prospectively collected data analysing ICU patients with a microbiologically confirmed complicated intra-abdominal infections.137 complicated intra-abdominal infections were included and stratified according to the adequacy of antimicrobial therapy (initial inadequate antimicrobial therapy [IIAT], n=44; initial adequate antimicrobial therapy [IAAT], n=93). The empirical use of enterococci/methicillin-resistant Staphylococcus aureus active agents and of carbapenems was associated with a higher rate of therapeutic adequacy (p=0.016 and p=0.01, respectively) while empirical double gram-negative and antifungal therapy did not.IAAT showed significantly lower mortality at 28 and 90days and increased clinical cure and microbiological eradication (p<0.01). In the logistic and Cox-regression models, IIAT and inadequate source control were the unique predictors of 28-day mortality.No costs differences were related to the adequacy of empirical therapy and source control. The empirical double gram-negative and antifungal therapy (p=0.03, p=0.04) as well as the isolation of multidrug-resistant (MDR) bacteria and the microbiological failure after targeted therapy were drivers of increased costs (p=0.004, p=0.04).IIAT and inadequate source control are confirmed predictors of mortality in ICU patients with complicated intra-abdominal infections. Empirical antimicrobial strategies and MDR may drive hospital costs.Adequate empirical therapy and prompt source control represent the mainstay of severe cIAI management, strongly influencing mortalityThe empirical use of two Gram-negative agents and antifungals does not increase the rate of therapeutical adequacyMultidrug resistance and inappropriate antimicrobial therapy are drivers of hospital costs.