Peritonitis medical therapy: Difference between revisions

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==Overview==
==Overview==
Treatment includes maintenance of hydration, preventing [[septicemia]] and correction of [[electrolytes]].  Empiric antibiotics should be initiated while awaiting culture results.  Coverage for [[Gram-positive bacteria|Gram positive]], [[Gram-negative bacteria|gram negative bacteria]] and [[Anaerobic organism|anaerobes]] should be initiated.  Surgery may be recommended in cases not responding to antibiotic treatment.  An [[Laparotomy|exploratory laparotomy]] may be needed to perform a full exploration and lavage of the [[peritoneum]].
Medical management of peritonitis includes hydration, prevention of [[septicemia]] and correction of [[electrolytes]].  Empiric coverage for [[Gram-positive bacteria|Gram positive]], [[Gram-negative bacteria|gram negative bacteria]] and [[Anaerobic organism|anaerobes]] should be initiated while awaiting culture results.  Surgery may be recommended in cases not responding to antibiotic treatment.  An [[Laparotomy|exploratory laparotomy]] may be required to perform a full exploration of the abdomen and to lavage the [[peritoneum]].


==Medical Therapy==
==Medical Therapy==

Revision as of 15:33, 15 March 2014

Peritonitis Main Page

Patient Information

Overview

Causes

Classification

Spontaneous Bacterial Peritonitis
Secondary Peritonitis

Differential Diagnosis

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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 bacteria and anaerobes should be initiated while awaiting culture results. Surgery may be recommended in cases not responding to antibiotic treatment. An exploratory laparotomy may be required to perform a full exploration of the abdomen and to lavage the peritoneum.

Medical Therapy

  • 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

Spontaneous Bacterial Peritionitis

  • An empiric antibiotic therapy should be started immediately as soon as the diagnosis is made. Third generation cephalosporin (ceftriaxone 1 g IV daily or cefotaxime 1 - 2 gm IV q6-8 hr ) are the preferred first line of treatment. [1]
  • Repeat paracentesis if no improvement after 48- 72 hrs , specially if the culture was negative.[1]
  • Ciprofloxacin can be used as a substitute for cephalosporin in the abscence of vomiting , shock or hepatic encephalopathy.[1]
  • Start with empirical antibiotic therapy for patients with fever , abdominal pain and tenderness inspite of neutrophils < 250 cells/ mm3.[1]
  • Albumin 1.5 g/kg body weight should be started at diagnosis and 1 gm/ kg body weight on day 3 to prevent renal failure.[2]


Peritonitis

  ▸  Primary Spontaneous Bacterial

  ▸  Secondary

  ▸  Dialysis (CAPD) Associated


Primary Spontaneous Bacterial
Preferred Regimen
Cefotaxime 2 gm IV q8h (q4h, if life-threatening infection)
OR
Ticaricillin Clavulanate 3.1 gm IV q6h
OR
Piperacillin Tazobactam 3.375 gm IV q6h (or 4-hour infusion of 3.375 gm q8h)
OR
Ceftriaxone 2 gm IV q24h
OR
Ertapenem 1 gm IV q24h
If resistant E. coli or Klebsiella species
Imipenem 500 mg IV q6h
OR
Meropenem 1000 mg IV q8h
OR
Doripenem 500 mg IV q8h (1 hr infusion)
If checking sensitivities, then start
Ciprofloxacin 400 mg IV q12h
OR
Levofloxacin 750 mg IV once daily
OR
Moxifloxacin 400 mg IV once daily
In addition to antibiotic, to decrease frequency of renal impairment start
IV Albumin 1.5 gm/kg at diagnosis and 1 gm/kg on day 3
Preventive regimen for chronic ascites
TMP-SMX-DS 1 tab po 5 days/week
OR
Ciprofloxacin 750 mg po once/week
Secondary
Preferred Regimen
For Mild/Moderate Peritonitis
Piperacillin Tazobactam 3.375 gm IV
/ 4.5 gm IV q8h / 4-hr infusion of 3.375 gm q8h
OR
Ticarcillin Clavulanate 3.1 gm IV q6h
OR
Ertapenem 1 gm IV q24h
OR
Moxifloxacin 400 mg IV q24h
For Severe Disease
Imipenem 500 mg to 1 gm IV q6h
OR
Meropenem 1 gm IV q8h
OR
Doripenem 500 mg IV q8h (1-hr infusion)
If Candida is suspected
Fluconazole 200-400 mg po/IV once daily
Alternate Regimen
For Mild/Moderate Disease
Ciprofloxacin 400 mg IV q12h
OR
Levofloxacin 750 mg IV q24h
PLUS
Metronidazole 1 gm IV q12h
OR
Cefepime 2 gm q12h
PLUS
Metronidazole 1 gm IV q12h
OR
Tigecycline 100 mg IV x 1 dose, then 50 mg q12h
For Severe Disease
AmpicillinI.M., I.V.: 1-2 g every 4-6 hours or 50-250 mg/kg/day in divided doses (maximum: 12 g/day)
PLUS
MetronidazoleI.V.: 500 mg every 8-12 hours or 1.5 g every 24 hours for for 4-7 days
PLUS
Ciprofloxacin 400 mg IV q8h
OR
Levofloxacin 750 mg IV q24h
OR
Ampicillin 2 gm IV q6h
PLUS
Metronidazole 1200 mg IV q12h
PLUS
Aminoglycoside
Dialysis (CAPD) Associated
Gram-positive cocci
VancomycinI.V.: 2000-3000 mg daily (or 30-60 mg/kg/day) in divided doses every 8-12 hours
Gram-negative bacilli
Cefepime I.V.: 2 g every 12 hours for 7-10 days.
OR
Ceftazidime .V.: 2 g every 8 hours for 4-7 days
OR
carbapenem
OR
Aztreonam 1 g I.V. or I.M. or 2 g I.V. every 8-12 hours
OR
▸'Ciprofloxacin I.V.: 400 mg every 12 hours for 7-14 days
OR
Gentamicin 3 mg/kg/day in 1-3 divided doses
Add an antifungal only if yeast seen on Gram-stain
Continuous therapy until culture results available
Beta-lactam continuous therapy
OR
Aminoglycoside intermittent therapy]]

References

  1. 1.0 1.1 1.2 1.3 Runyon, BA.; Shuhart, MC.; Davis, GL.; Bambha, K.; Cardenas, A.; Davern, TJ.; Day, CP.; Han, SH.; Howell, CD. (2009). "Management of adult patients with ascites due to cirrhosis: an update". Hepatology. 49 (6): 2087–107. doi:10.1002/hep.22853. PMID 19475696. Unknown parameter |month= ignored (help)
  2. Grange, JD.; Amiot, X. (2000). "[Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis]". Gastroenterol Clin Biol. 24 (3): 378–9. PMID 10866518. Unknown parameter |month= ignored (help)


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