Peritonitis medical therapy: Difference between revisions

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===Antibiotic therapy===
===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. <ref name="Runyon-2009">{{Cite journal  | last1 = Runyon | first1 = BA. | last2 = Shuhart | first2 = MC. | last3 = Davis | first3 = GL. | last4 = Bambha | first4 = K. | last5 = Cardenas | first5 = A. | last6 = Davern | first6 = TJ. | last7 = Day | first7 = CP. | last8 = Han | first8 = SH. | last9 = Howell | first9 = CD. | title = Management of adult patients with ascites due to cirrhosis: an update. | journal = Hepatology | volume = 49 | issue = 6 | pages = 2087-107 | month = Jun | year = 2009 | doi = 10.1002/hep.22853 | PMID = 19475696 }}</ref>
*Repeat paracentessis if no improvement after  48- 72 hrs , specially if the culture was negative.<ref name="Runyon-2009">{{Cite journal  | last1 = Runyon | first1 = BA. | last2 = Shuhart | first2 = MC. | last3 = Davis | first3 = GL. | last4 = Bambha | first4 = K. | last5 = Cardenas | first5 = A. | last6 = Davern | first6 = TJ. | last7 = Day | first7 = CP. | last8 = Han | first8 = SH. | last9 = Howell | first9 = CD. | title = Management of adult patients with ascites due to cirrhosis: an update. | journal = Hepatology | volume = 49 | issue = 6 | pages = 2087-107 | month = Jun | year = 2009 | doi = 10.1002/hep.22853 | PMID = 19475696 }}</ref>
*Ciprofloxacin  can be used as a substitute for cephalosporin  in the abscence of [[vomiting]] , [[shock]] or [[hepatic encephalopathy]].<ref name="Runyon-2009">{{Cite journal  | last1 = Runyon | first1 = BA. | last2 = Shuhart | first2 = MC. | last3 = Davis | first3 = GL. | last4 = Bambha | first4 = K. | last5 = Cardenas | first5 = A. | last6 = Davern | first6 = TJ. | last7 = Day | first7 = CP. | last8 = Han | first8 = SH. | last9 = Howell | first9 = CD. | title = Management of adult patients with ascites due to cirrhosis: an update. | journal = Hepatology | volume = 49 | issue = 6 | pages = 2087-107 | month = Jun | year = 2009 | doi = 10.1002/hep.22853 | PMID = 19475696 }}</ref>
*Start with empirical antibiotic therapy for patients with fever , abdominal pain  and tenderness inspite of neutrophils < 250 cells/ mm3.<ref name="Runyon-2009">{{Cite journal  | last1 = Runyon | first1 = BA. | last2 = Shuhart | first2 = MC. | last3 = Davis | first3 = GL. | last4 = Bambha | first4 = K. | last5 = Cardenas | first5 = A. | last6 = Davern | first6 = TJ. | last7 = Day | first7 = CP. | last8 = Han | first8 = SH. | last9 = Howell | first9 = CD. | title = Management of adult patients with ascites due to cirrhosis: an update. | journal = Hepatology | volume = 49 | issue = 6 | pages = 2087-107 | month = Jun | year = 2009 | doi = 10.1002/hep.22853 | PMID = 19475696 }}</ref>
*[[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.<ref name="Grange-2000">{{Cite journal  | last1 = Grange | first1 = JD. | last2 = Amiot | first2 = X. | title = [Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis]. | journal = Gastroenterol Clin Biol | volume = 24 | issue = 3 | pages = 378-9 | month = Mar | year = 2000 | doi =  | PMID = 10866518 }}</ref>


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==References==
==References==

Revision as of 05:09, 6 February 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]

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

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 paracentessis 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
Dialysis (CAPD) Associated
Gram-positive cocci
Vancomycin
Gram-negative bacilli
Cefepime
OR
Ceftazidime
OR
carbapenem
OR
Aztreonam
OR
▸'Ciprofloxacin
OR
Gentamicin
Add an antifungal only if yeast seen on Gram-stain
Continuous therapy until culture results available
Beta-lactam continuous therapy
OR
Aminoglycoside intermittent therapy]]
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
Ampicillin
PLUS
Metronidazole
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

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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