Peritonitis medical therapy

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.
• Repeat paracentessis if no improvement after 48- 72 hrs , specially if the culture was negative.
• Ciprofloxacin can be used as a substitute for cephalosporin in the abscence of vomiting , shock or hepatic encephalopathy.
• Start with empirical antibiotic therapy for patients with fever , abdominal pain and tenderness inspite of neutrophils < 250 cells/ mm3.
• 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.

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

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