View source for Peritonitis medical therapy

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{{Peritonitis}}
{{CMG}} {{AE}} {{chetan}}

==Overview==
Medical management of [[peritonitis]] includes hydration, prevention of [[septicemia]], and [[Electrolyte disturbance|correction of electrolytes]].  Empiric coverage for [[gram positive]], [[gram negative]], and [[anaerobes|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 disturbance]]s.
* [[Antibiotics]] are usually administered [[intravenous]]ly, 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:'''<ref name="pmid25819304">{{cite journal| author=Dever JB, Sheikh MY| title=Review article: spontaneous bacterial peritonitis - bacteriology, diagnosis, treatment, risk factors and prevention. | journal=Aliment Pharmacol Ther | year= 2015 | volume= 41 | issue= 11 | pages= 1116-31 | pmid=25819304 | doi=10.1111/apt.13172 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25819304  }} </ref>
:*Preferred regimen (1): [[Cefotaxime]] 2 g IV q8h for 5 days
:*Preferred regimen (2): [[Ceftriaxone]] 1 g IV q12h for 5 days
:*Alternative regimen (penicillin allergy): [[Levofloxacin]] 500 mg IV q24h for 5 days

*'''2. Nosocomial Spontaneous Bacterial Peritonitis:'''<ref name="pmid25819304">{{cite journal| author=Dever JB, Sheikh MY| title=Review article: spontaneous bacterial peritonitis - bacteriology, diagnosis, treatment, risk factors and prevention. | journal=Aliment Pharmacol Ther | year= 2015 | volume= 41 | issue= 11 | pages= 1116-31 | pmid=25819304 | doi=10.1111/apt.13172 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25819304  }} </ref>
:*Preferred regimen: [[Pipercillin-Tazobactam]] 3.375 g IV q6h {{and}} [[Vancomycin]] 1 g IV q12h for 5 days

*'''3. Vancomycin-resistant Enterococcus Spontaneous Bacterial Peritonitis:'''<ref name="pmid25819304">{{cite journal| author=Dever JB, Sheikh MY| title=Review article: spontaneous bacterial peritonitis - bacteriology, diagnosis, treatment, risk factors and prevention. | journal=Aliment Pharmacol Ther | year= 2015 | volume= 41 | issue= 11 | pages= 1116-31 | pmid=25819304 | doi=10.1111/apt.13172 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25819304  }} </ref>
:*Preferred regimen: [[Linezolid]] 600 mg PO/IV q12h {{or}} [[Daptomycin]] 6 mg/kg IV q24h

*'''4. Extended spectrum beta-lactamase Enterobacteriaceae Spontaneous Bacterial Peritonitis(ESBL Enterobacteriaceae SBP):'''<ref name="pmid25819304">{{cite journal| author=Dever JB, Sheikh MY| title=Review article: spontaneous bacterial peritonitis - bacteriology, diagnosis, treatment, risk factors and prevention. | journal=Aliment Pharmacol Ther | year= 2015 | volume= 41 | issue= 11 | pages= 1116-31 | pmid=25819304 | doi=10.1111/apt.13172 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25819304  }} </ref>
:*Preferred regimen: [[Meropenem]] 1 g IV q8h for 5-7 days

====Peritonitis, secondary to bowel  perforation====
*'''1. Community-acquired infection in adults''' <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=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. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
:*'''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:'''
:::*Preferred regimen (1): [[Cefazolin]] 1–2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (2): [[Cefuroxime]] 1.5 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (3): [[Ceftriaxone]] 1–2 g IV q12–24 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (4): [[Cefotaxime]] 1–2 g IV  q6–8 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (5): [[Ciprofloxacin]] 400 mg IV q12h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (6): [[Levofloxacin]] 750 mg IV  q24h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h

:*'''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''' <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=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. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
:*'''2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other  multidrug resistant gram-negative bacilli:'''
::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
::*Preferred regimen (2): Imipenem-cilastatin 500 mg IV 6 h {{or}} 1 g  q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
::*Preferred regimen (3): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV every 8–12 h or 1500 mg q24h
::*Preferred regimen (4): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
::*Preferred regimen (6): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h

:*'''2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:'''
::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (2): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (3): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h

:*'''2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:'''
::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (2): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (3): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h

:*'''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'''<ref> {{cite book | last =   Ferri | first = Fred  | title = Ferri's Clinical Advisor 2016: 5 Books in 1, 1e (Ferri's Medical Solutions)
 | publisher =  | location =  | year = 2015 | isbn = 978-0323280471 }}</ref>
:*Preferred regimen (1): [[Piperacillin-tazobactam]] 3.375 g IV q6h {{or}} 4.5 g IV q8h
:*Preferred regimen (2): [[Ticarcillin-clavulanate]] 3.1 g IV q6h.
:*Alternative regimen (1): [[Ciprofloxacin]] 400 mg IV q12h {{and}} [[Metronidazole]] 1 g IV q12h
:*Alternative regimen (2): [[Levofloxacin]] 750 mg IV q24h {{and}} [[Metronidazole]] 1 g IV q12h.

*'''2. Severe life-threatening disease'''<ref> {{cite book | last =   Ferri | first = Fred  | title = Ferri's Clinical Advisor 2016: 5 Books in 1, 1e (Ferri's Medical Solutions)
 | publisher =  | location =  | year = 2015 | isbn = 978-0323280471 }}</ref>
:*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''' <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=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. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
:*'''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:'''
:::*Preferred regimen (1): [[Cefazolin]] 1–2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (2): [[Cefuroxime]] 1.5 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (3): [[Ceftriaxone]] 1–2 g IV q12–24 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (4): [[Cefotaxime]] 1–2 g IV  q6–8 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (5): [[Ciprofloxacin]] 400 mg IV q12h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (6): [[Levofloxacin]] 750 mg IV  q24h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h

:*'''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''' <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=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. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
:*'''2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other  multidrug resistant gram-negative bacilli:'''
::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
::*Preferred regimen (2): Imipenem-cilastatin 500 mg IV 6 h {{or}} 1 g  q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
::*Preferred regimen (3): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV every 8–12 h or 1500 mg q24h
::*Preferred regimen (4): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
::*Preferred regimen (6): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h

:*'''2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:'''
::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (2): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (3): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h

:*'''2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:'''
::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (2): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (3): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h

:*'''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 {{withorwithout}} [[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 {{withorwithout}} [[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 {{withorwithout}} [[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 {{withorwithout}} [[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''' <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=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. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
:*'''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:'''
:::*Preferred regimen (1): [[Cefazolin]] 1–2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (2): [[Cefuroxime]] 1.5 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (3): [[Ceftriaxone]] 1–2 g IV q12–24 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (4): [[Cefotaxime]] 1–2 g IV  q6–8 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (5): [[Ciprofloxacin]] 400 mg IV q12h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (6): [[Levofloxacin]] 750 mg IV  q24h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h

:*'''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''' <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=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. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
:*'''2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other  multidrug resistant gram-negative bacilli:'''
::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
::*Preferred regimen (2): Imipenem-cilastatin 500 mg IV 6 h {{or}} 1 g  q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
::*Preferred regimen (3): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV every 8–12 h or 1500 mg q24h
::*Preferred regimen (4): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
::*Preferred regimen (6): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h

:*'''2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:'''
::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (2): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (3): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h

:*'''2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:'''
::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (2): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (3): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h

:*'''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==
{{reflist|2}}

[[Category:Needs content]]
[[Category:Gastroenterology]]
[[Category:Inflammations]]
[[Category:Diseases involving the fasciae]]
[[Category:Medical emergencies]]
[[Category:Surgery]]
[[Category:Emergency medicine]]
[[Category:Infectious disease]]

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