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]

Overview

Peritonitis management depends on the severity of the symptoms. Treatment widely includes maintaining adequate hydration, preventing septicemia and correction of electrolytes. Empirical therapy should be started while awaiting culture results. Coverage for Gram positive, gram negative bacteria and anaerobes must be provided with. Surgery may be recommended in cases not responding to antibiotic treatment. An exploratory laparotomy may be needed to perform a full exploration and lavage of the peritoneum.

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 paracentesis 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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