Secondary peritonitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2]
Overview
Medical management of secondary 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
For secondary peritonitis appropriate use of antimicrobial regimen, serves as an adjunctive treatment to surgical intervention.[1]The general principles guiding the treatment of secondary peritonitis are 4-fold, as follows:
- Control the infectious source
- Eliminate bacteria and toxins
- Maintain organ system function
- Control the inflammatory process
The treatment of peritonitis is multidisciplinary, with the complimentary application of medical, operative and nonoperative interventions. Medical support includes the following:
- Systemic antibiotic therapy
- Intensive care with hemodynamic, pulmonary, and renal support
- Correction of electrolyte and coagulation abnormalities
- Nutrition and metabolic support
- Inflammatory response modulation therapy
Critical aspects of treatment should focus on:
- Early operative approach in order to identify the source of peritonitis
- Clearing of the infection in the peritoneal cavity by means of lavage, adequate drainage, and antibiotics
- Intubation and decompression of GI tract and control of paralytic ileus.
- Metabolic correction (acid-base balance, serum electrolytes, protein metabolism)
- Restoration and support of visceral function (kidney, liver, lung, heart) and prevention of complications.
Depending on the severity of the patient's state, the management of secondary 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.
- The response to therapy can be documented, if necessary, by a decrease in the PMN count of at least 50% on repeat paracentesis 48 hours after initiation of therapy.
- Probiotic supplement (containing Lactobacillus acidophilus among other species), 5 - 10 billion colony forming units (CFUs) a day, for gastrointestinal and immune health.
- Probiotics can be especially helpful when taking antibiotics because probiotics can help restore the balance of bacterial flora in the intestines.
| Empirical treatment for Secondary Peritonitis | |
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| Empiric antibiotic therapy[2] | Empiric antifungal therapy |
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Mild or moderate secondary peritonitis
Severe peritonitis or Immunocompromised patients
Uncomplicated: Perforation is operated within 12-24 hours
Complicated: Perforation is operated lately or necrotic/gangrenous appendix is developed.
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Emperical antifungal therapy is generally indicated in secondary peritonitis except if the patient has one of the following risk factors:
If the patient is clinically stable and no history of prior long term azole therpy: Fluconazole 400-800 mg IV/PO Q24H If the patient is clinically unstable or patient with history of prior long-term azole therapy: Micafungin 100mg IV Q24H |
References
- ↑ Bosscha K, van Vroonhoven TJ, van der Werken C (1999). "Surgical management of severe secondary peritonitis". Br J Surg. 86 (11): 1371–7. doi:10.1046/j.1365-2168.1999.01258.x. PMID 10583280.
- ↑ 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. Surg Infect (Larchmt) 11 (1):79-109. DOI:10.1089/sur.2009.9930 PMID: 20163262