Peritonitis medical therapy

Peritonitis Main Page
Patient Information
Overview
Causes
Classification Spontaneous Bacterial Peritonitis Secondary Peritonitis
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2] Shivani Chaparala M.B.B.S [3]

Overview

Medical management of 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

The general principles guiding the treatment of peritonitis are 4-fold, as follows:

• Control the infectious source
• Eliminate bacteria and toxins
• Maintain organ system function
• Control the inflammatory process

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.
• 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 CFUs (colony forming units) a day, for gastrointestinal and immune health.
• Probiotics can be especially helpful when taking antibiotics, because probiotics can help restore the balance of "good" bacteria in the intestines.

Empirical treatment for peritonitis
Primary Peritonitis	Secondary Peritonitis	Peritonitis related to peritoneal dialysis
Ceftriaxone 1gm IV Q12H x 5days Penicillin allergic patients: Moxifloxacin 400mg IV/PO Q24H x 5days Patient with serum creatinine >1mg/dl, BUN >30mg/dl or total bilurubi >4mg/dl should also receive Albumin (which may have anti-inflammatory effects in addition to expanding plasma volume) prevents further renal impairment and reduces mortality) 25% 1.5g/kg on day 1 and 1gm/kg on day 3 (round to the nearest 12.5gm) Duration: 5days Variants of spontaneous bacterial peritonitis Community-acquired Spontaneous Bacterial Peritonitis: 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 Nosocomial Spontaneous Bacterial Peritonitis: Preferred regimen: Piperacillin-Tazobactam 3.375 g IV q6h AND Vancomycin 1 g IV q12h for 5 days Vancomycin-resistant Enterococcus Spontaneous Bacterial Peritonitis: Preferred regimen: Linezolid 600 mg PO/IV q12h OR Daptomycin 6 mg/kg IV q24h Extended spectrum beta-lactamase Enterobacteriaceae Spontaneous Bacterial Peritonitis(ESBL Enterobacteriaceae SBP): Preferred regimen: Meropenem 1 g IV q8h for 5-7 days	Mild or moderate secondary peritonitis Ertapenem 1gm IV Q24H Penicillin allergic patients: Ciprofloxacin 400mg IV Q12H + Metronidazole 500mg IV Q8H Severe peritonitis or Immunocompromised patients Piperacillin/ tazobactam 3.375gm IV Q6H Penicillin allergic patient: Cefepime 1gm IV Q8H + Metronidazole 500gm IV Q8H Severe PCN allergic patient: Vancomycin + Aztreonam 1gm IV Q8H or Ciprofloxacin 400mg IV Q8H + Metronidazole 500mg IV Q8H Duration of empiric therapy depends on whether the peritonitis is complicated or uncomplicated: Uncomplicated: Perforation is operated with in 12-24 hours Duration of empiric therapy: 24-48 Complicated: Perforation is operated lately or necrotic/gangrenous appendix is developed. Duration of empiric therapy: 4 days unless adequate source control is not achieved.	Mild or moderate secondary peritonitis Intraperitoneal therapy is preferred Anuric patient Cefazolin 15mg/kg in one bag + Gentamicin 2mg/kg in one bag loading dose, then Gentamicin 0.6mg/kg in one bag Q24H Patient with urine output > 100ml/day Ceftazidime 1gm in one bag Q24H Sever illness Systemic therapy is preferred. Initial dose: Vancomycin + Gentamicin 2mg/kg or Ceftazidime 1gm IV or Ciprofloxacin 400mg IV Maintainance dose: dosage level depending on renal funtion Duration: 10-14days
Empiric antifungal therapy
Emperical antifungal therapy is generally indicated in secondary peritonitis excepet if the patient has one of the following risk factors: Esophageal perforation Immunosuppression Prolonged antacid therapy Prolonged antibiotic therapy Prolonged hospitalization Persistant GI leak 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 therpy: Micafungin 100mg IV Q24H

Antimicrobial Regimens

• 1. Community-acquired infection in adults

Peritonitis Secondary to Appendicitis, Diverticulitis, and Bowel Perforation

• 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

• 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 ± 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 ± 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 ± 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 ± 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.

Spontaneous Bacterial Peritonitis

• 1. Community-acquired Spontaneous Bacterial Peritonitis:

• 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:

• Preferred regimen: Piperacillin-Tazobactam 3.375 g IV q6h AND Vancomycin 1 g IV q12h for 5 days

• 3. Vancomycin-resistant Enterococcus Spontaneous Bacterial Peritonitis:

• 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):

• Preferred regimen: Meropenem 1 g IV q8h for 5-7 days

Peritonitis Secondary to Dialysis

• 1. Mild-moderate disease

• 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

• Preferred regimen (1): Imipenem 500 mg IV q6h
• Preferred regimen (2): Meropenem 1 g IV q8h