• Acute inflammatory response of peritoneal lining
• Caused by:

microorganisms

chemicals

irradiation

foreign-boyd injury

• Purulent collection of fluid
• Separated from surrounding tissue
• Contains:

necrotic debris

bacteria

inflammatory cells

• Often spontaneous
• Bacteria comes from outside of peritoneum -- through bloodstream or instrumentation
• Usually caused by single organism

• Alcoholic cirrhosis
• Continuous ambulatory peritoneal dialysis

• Most common
• Infectious organism comes from within the abdominal cavity (GI flora)
• Usually polymicrobial

• Perforation (stomach, small or large bowel, urinary bladder, appendix, gallbladder, diverticula)
• Post-Operative (peritoneal contamination)
• Post-Traumatic (blunt or penetrating)

• Occurs in critically ill patients
• Persists or recurs at least 48 hrs after completion of adequate treating for primary or secondary peritonitis
• Need to consider less common and multi-drug resistant bacteria and fungal pathogens

• Candida
• VRE
• Pseudomonas
• Serratia
• MRSA

Bacterial Invasion

↓

Peritonitis

↓

Ileus/3rd spacing

↓

Sepsis/Septic Shock

↓

End organ damage

↓

Death

• Inflammation of biliary tract and/or gallbladder
• Caused by:

cholelithiasis (gall stones)

cancer and strictures

• Fever
• Leukocytosis
• Right Upper Quadrant pain
• N/D
• AST/ALT
• Bilirubin
• ALP
• Amylase

• Klebsiella
• Enterobacter
• E. coli
• Proteus
• Enterococcus
• Anaerobes (Bacteroides fragilis)

• Drain biliary tree or gall bladder
• Culture the drainage, tissue, and blood
• Antibiotics if gallbladder not removed and refine when culture and sensitivity come back
• Provides supportive treatments for blood pressure, pain, and nausea

• Treat for 2 days after symptoms absent -- do not treat longer than 5-7 days if possible
• Stop the antibiotics after gallbladder is removed unless there is perforation or gangrene

Gentamicin + ampicillin

OR

Fluoroquinolone

OR

3rd or 4th Gen Cephalosporin

+

metronidazole or clindamycin

OR

Ampicillin/Sulbactam

OR

Ertapenem

3rd or 4th Cephalosporin

+

metronidazole or clindamycin

OR

Piperacillin/Tazobactam

OR

Imipenem or Meropenem

• Fever
• Leukocytosis
• abdominal pain
• N/V
• AST/ALT
• decreased bowel sounds

• Surgery/drainage (rare)
• Culture blood, paracentesis fluid
• Antibiotics
• Supportive treatment, especially fluids
• Narrow antibiotic coverage
• Treat 2 days after symptoms are absent = 5-7 days -->longer to peritoneal dialysis

• Enteric G-
• Anaerobes (rare)
• Enterococcus
• Streptococcus (possible viridans infection)

• 3rd Gen Cephalosporins
• Piperacillin/Tazobactam
• Ampicillin/Sulbactam
• Fluoroquinolones

If ESBL (E. coli, Klebsiella), use carbapenems

• Staph. aureus
• Staph. epidermidis
• G- rods (occasionally) -- G- enterics, rarely Non-enteric
• Candida

Intraperitoneal Therapy Preferred

Antibiotics dissolved in dialysate

Vancomycin sol'n

+

Ceftazidime sol'n or Gentamicin sol'n

Other regimens possible

• Vancomycin plus Ceftazidime
• If MRSA not identified, switch Vancomycin with:

Nafcillin

Oxacillin

Cefazolin

Develops acutely

• Fever
• Leukocytosis with left shift
• Abdominal pain
• Abdominal guarding or rigidness
• N/V
• Decreased bowel sounds
• Tachycardia

• Surgical repair and excision
• Culture blood and peritoneal fluid
• Treat with antibiotics
• Supportive treatment such as fluids
• Narrow antibiotic therapy if possible

Remember: secondary peritonitis is always polymicrobial and anaerobes might not grow on culture

• Enteric G-
• Anaerobes (Bacteroides fragilis)
• G+ (Enterococcus, Streptococcus)
• Non-Enteric G- (P. aeruginosa)

• Piperacillin/Tazobactam
• Carbapenems
• Tigecycline
• 3rd or 4th Gen Cephalosporin + metronidazole or clindamycin

Treat for 2 days after asymptomatic -- limit to 5-7 days if possible

Blunt or sharp trauma -- if antibiotics initiated within 3-4 hrs, treat 2-3 days

Appendicitis:

1 dose antibiotic if only inflammed and removed intact

Treat 5-7 days if ruptured or gangrenous appendix

• Fluconazole
• Echinocandin or Amphotericin B if life-threatening

• Fever
• Leukocytosis with left shift
• Abdominal pain
• Symptoms are not always persistent

• Can be places other than abdomen (lung, brain, skin)

• Drain the abscess
• Culture blood and drainage
• Antibiotics
• Pre-drainage -- metronidazole or clindamycin
• Post-drainage -- beta-lactams, don't use aminoglycosides
• Supportive treatment with fluids
• Treat for at least 7 days

• ALWAYS AN ANAEROBE +
• G- Enterics

OR

• G+ (Enterococcus, Streptococcus)

If above the diaphragm, most likely G+ mouth flora

Treat the same as secondary peritonitis

• Ampicillin/Sulbactam
• Fluoroquinolone + Metronidazole or Clindamycin
• Piperacillin/Tazobactam
• Carbapenem
• Tigecycline
• 3rd or 4th Gen Cephalosporin + Metronidazole or Clindamycin

Monitor for improvement or treatment failure

Improving:

resolution of fever

hemodynamic stability

absence or decline in abdominal pain

lab value improvement of WBC, LFT, and Bilirubin

Return or improvement of GI function