Peritonitis medical therapy

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Peritonitis Main Page

Patient Information

Overview

Causes

Classification

Spontaneous Bacterial Peritonitis
Secondary Peritonitis

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2]

Overview

Medical management of peritonitis includes hydration, prevention of septicemia, and correction of electrolytes. Empiric coverage for gram positive, gram negative, and anaerobic bacteria should be initiated promptly while awaiting culture results. Either open abdominal surgery or an exploratory laparotomy is recommended.

Medical Therapy

Depending on the severity of the patient's state, the management of peritonitis may include:

  • General supportive measures such as vigorous intravenous rehydration and correction of electrolyte disturbances.
  • Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum antibiotics often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis; once one or more agents are actually isolated, therapy will of course be targeted on them.

Antibiotic therapy

Peritonitis, spontaneous bacterial

  • 1. Community-acquired Spontaneous Bacterial Peritonitis:[1]
  • Preferred regimen (1): Cefotaxime 2 g IV Q 8 h for 5 days
  • Preferred regimen (2): Ceftriaxone 1 g IV bid for 5 days
  • Alternative regimen: If allergic to Penicillin give Levofloxacin 500 mg IV daily for 5 days
  • 2. Nosocomial Spontaneous Bacterial Peritonitis:[1]
  • Preferred regimen: Tazobactam–pipercillin 3.375 g IV Q 6 hrs AND Vancomycin 1 g IV Q 12 hrs for 5 days
  • 3. Vancomycin-resistant Enterococcus Spontaneous Bacterial Peritonitis:[1]
  • 4. Extended spectrum beta-lactamase Enterobacteriaceae Spontaneous Bacterial Peritonitis(ESBL Enterobacteriaceae SBP):[1]
  • Preferred regimen: Meropenem 1 g IV Q 8 h for 5-7 days

Peritonitis, secondary to bowel perforation

  • 1. Community-acquired infection in adults [2]
  • 1.1. Mild-to-moderate severity (perforated or abscessed appendicitis and other infections of mild-to-moderate severity):
  • 1.1.1. Single agent:
  • Preferred regimen (1): Cefoxitin 2 g IV q6h
  • Preferred regimen (2): Ertapenem 1 g IV q24h
  • Preferred regimen (3): Moxifloxacin 400 mg IV q24h
  • Preferred regimen (4): Tigecycline 100 mg initial dose, THEN 50 mg IV q12h
  • Preferred regimen (5): Ticarcillin-clavulanic acid 3.1 g IV q6h; FDA labeling indicates 200 mg/kg/day in divided doses every 6 h for moderate infection
  • 1.1.2. Combination:
  • 1.2. High risk or severity (severe physiologic disturbance, advanced age, or immunocompromised state):
  • 1.2.1. Single agent:
  • Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h
  • Preferred regimen (2): Meropenem 1 g IV q8h
  • Preferred regimen (3): Doripenem 500 mg IV q8h
  • Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h
  • 1.2.2. Combination:
  • Preferred regimen (1): Cefepime 2 g q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Preferred regimen (2): Ceftazidime 2 g q8h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Preferred regimen (3): Ciprofloxacin 400 mg q12h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Preferred regimen (4): Levofloxacin 750 mg q24h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.
  • 2. Health Care–Associated Complicated Intra-abdominal Infection [2]
  • 2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other multidrug resistant gram-negative bacilli:
  • 2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:
  • 2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:
  • 2.4.Methicillin-resistant Staphylococcus aureus (MRSA):
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12 h
  • Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

Peritonitis, secondary to dialysis

  • 1. Mild-moderate disease[3]
  • 2. Severe life-threatening disease[4]
  • Preferred regimen (1): Imipenem 500 mg IV q6h
  • Preferred regimen (2): Meropenem 1 g IV q8h

Peritonitis, secondary to ruptured appendix

  • 1. Community-acquired infection in adults [2]
  • 1.1. Mild-to-moderate severity (perforated or abscessed appendicitis and other infections of mild-to-moderate severity):
  • 1.1.1. Single agent:
  • Preferred regimen (1): Cefoxitin 2 g IV q6h
  • Preferred regimen (2): Ertapenem 1 g IV q24h
  • Preferred regimen (3): Moxifloxacin 400 mg IV q24h
  • Preferred regimen (4): Tigecycline 100 mg initial dose, THEN 50 mg IV q12h
  • Preferred regimen (5): Ticarcillin-clavulanic acid 3.1 g IV q6h; FDA labeling indicates 200 mg/kg/day in divided doses every 6 h for moderate infection
  • 1.1.2. Combination:
  • 1.2. High risk or severity (severe physiologic disturbance, advanced age, or immunocompromised state):
  • 1.2.1. Single agent:
  • Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h
  • Preferred regimen (2): Meropenem 1 g IV q8h
  • Preferred regimen (3): Doripenem 500 mg IV q8h
  • Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h
  • 1.2.2. Combination:
  • Preferred regimen (1): Cefepime 2 g q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Preferred regimen (2): Ceftazidime 2 g q8h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Preferred regimen (3): Ciprofloxacin 400 mg q12h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Preferred regimen (4): Levofloxacin 750 mg q24h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.
  • 2. Health Care–Associated Complicated Intra-abdominal Infection [2]
  • 2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other multidrug resistant gram-negative bacilli:
  • 2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:
  • 2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:
  • 2.4.Methicillin-resistant Staphylococcus aureus (MRSA):
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12 h
  • Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.
  • 3. Community-acquired infection in pediatric patients
  • 3.1. Single agent:
  • Preferred regimen (1): Ertapenem 3 months to 12 years 15 mg/kg bid (not to exceed 1 g/day) Every 12 h, older than 13 years 1 g/day Every 24 h OR
  • Preferred regimen (2): Meropenem 60 mg/kg/day q8h
  • Preferred regimen (3): Imipenem-cilastatin 60–100 mg/kg/day IV q6h
  • Preferred regimen (4): Ticarcillin-clavulanate 200–300 mg/kg/day IV of ticarcillin component q4–6 h
  • Preferred regimen (5): Piperacillin-tazobactam 200–300 mg/kg/day IV of piperacillin component q6–8 h
  • 3.2.Combination:
  • Preferred regimen(1): Ceftriaxone 50–75 mg/kg/day q12–24 h, AND Metronidazole 30–40 mg/kg/day q8h
  • Preferred regimen(2): Cefotaxime 150–200 mg/kg/day q6–8 h, AND Metronidazole 30–40 mg/kg/day q8h
  • Preferred regimen(3): Cefepime 100 mg/kg/day q12h, AND Metronidazole 30–40 mg/kg/day q8h
  • Preferred regimen(4): Ceftazidime 150 mg/kg/day q8 h, AND Metronidazole 30–40 mg/kg/day q8h
  • Preferred regimen(5): Gentamicin 3–7.5 mg/kg/day q2–4 h, AND Metronidazole 30–40 mg/kg/day q8h ± Ampicillin 200 mg/kg/day q6h
  • Preferred regimen(6): Gentamicin 3–7.5 mg/kg/day q2–4 h, AND Clindamycin 20–40 mg/kg/day q6–8 h ± Ampicillin 200 mg/kg/day q6h
  • Preferred regimen(7): Tobramycin 3.0–7.5 mg/kg/day q8–24 h, AND Metronidazole 30–40 mg/kg/day q8h ± Ampicillin 200 mg/kg/day q6h
  • Preferred regimen(8): Tobramycin 3.0–7.5 mg/kg/day q8–24 h, AND Clindamycin 20–40 mg/kg/day q6–8 h ± Ampicillin 200 mg/kg/day q6h
  • Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

Peritonitis, secondary to ruptured diverticula

  • 1. Community-acquired infection in adults [2]
  • 1.1. Mild-to-moderate severity (perforated or abscessed appendicitis and other infections of mild-to-moderate severity):
  • 1.1.1. Single agent:
  • Preferred regimen (1): Cefoxitin 2 g IV q6h
  • Preferred regimen (2): Ertapenem 1 g IV q24h
  • Preferred regimen (3): Moxifloxacin 400 mg IV q24h
  • Preferred regimen (4): Tigecycline 100 mg initial dose, THEN 50 mg IV q12h
  • Preferred regimen (5): Ticarcillin-clavulanic acid 3.1 g IV q6h; FDA labeling indicates 200 mg/kg/day in divided doses every 6 h for moderate infection
  • 1.1.2. Combination:
  • 1.2. High risk or severity (severe physiologic disturbance, advanced age, or immunocompromised state):
  • 1.2.1. Single agent:
  • Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h
  • Preferred regimen (2): Meropenem 1 g IV q8h
  • Preferred regimen (3): Doripenem 500 mg IV q8h
  • Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h
  • 1.2.2. Combination:
  • Preferred regimen (1): Cefepime 2 g q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Preferred regimen (2): Ceftazidime 2 g q8h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Preferred regimen (3): Ciprofloxacin 400 mg q12h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Preferred regimen (4): Levofloxacin 750 mg q24h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
  • Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.
  • 2. Health Care–Associated Complicated Intra-abdominal Infection [2]
  • 2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other multidrug resistant gram-negative bacilli:
  • 2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:
  • 2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:
  • 2.4.Methicillin-resistant Staphylococcus aureus (MRSA):
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12 h
  • Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

References

  1. ↑ 1.0 1.1 1.2 1.3 Dever JB, Sheikh MY (2015). "Review article: spontaneous bacterial peritonitis - bacteriology, diagnosis, treatment, risk factors and prevention". Aliment Pharmacol Ther. 41 (11): 1116–31. doi:10.1111/apt.13172. PMID 25819304.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ; et al. (2010). "Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America". Clin Infect Dis. 50 (2): 133–64. doi:10.1086/649554. PMID 20034345.
  3. ↑ Ferri, Fred (2015). Ferri's Clinical Advisor 2016: 5 Books in 1, 1e (Ferri's Medical Solutions). ISBN 978-0323280471.
  4. ↑ Ferri, Fred (2015). Ferri's Clinical Advisor 2016: 5 Books in 1, 1e (Ferri's Medical Solutions). ISBN 978-0323280471.


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