What is the treatment for peritonitis?

Treatment of Peritonitis

The treatment of peritonitis requires immediate surgical intervention for source control, along with rapid fluid resuscitation and early broad-spectrum antimicrobial therapy to reduce morbidity and mortality. 1

Initial Management

Resuscitation and Stabilization

• Rapid restoration of intravascular volume and physiological stability (Level A-II) 1
• For patients with septic shock, resuscitation should begin immediately when hypotension is identified 1
• For patients without volume depletion, IV fluid therapy should begin when intra-abdominal infection is first suspected 1

Antimicrobial Therapy

• Start antimicrobial therapy as soon as peritonitis is diagnosed or strongly suspected 1
• For patients with septic shock, antibiotics should be administered immediately 1
• For patients without septic shock, antibiotics should be started in the emergency department 1

Empiric Antibiotic Regimens

• Community-acquired peritonitis: Third-generation cephalosporins (e.g., cefotaxime), amoxicillin/clavulanic acid, or piperacillin/tazobactam 1, 2
• Hospital-acquired peritonitis: Broader spectrum antibiotics covering resistant organisms 1
• Spontaneous bacterial peritonitis (SBP): Third-generation cephalosporins are first-line; alternatives include amoxicillin/clavulanic acid or quinolones 1

Timing of Surgical Intervention

• Patients with diffuse peritonitis should undergo emergency surgical procedure as soon as possible, even while resuscitation continues 1
• Delay in surgical intervention is associated with increased morbidity and mortality 3

Source Control

Surgical Approaches

• An appropriate source control procedure to drain infected foci, control ongoing contamination, and restore anatomical function is recommended for nearly all patients 1
• The specific surgical approach depends on the cause of peritonitis:
  • Perforated peptic ulcer: Surgery is the treatment of choice; simple closure with or without omental patch for small perforations (<2 cm) 1
  • Small bowel perforation: Primary repair for small perforations 1
  • Appendicitis: Open or laparoscopic appendectomy 1
  • Diverticulitis with peritonitis: Hartmann's procedure in critically ill patients; primary resection with anastomosis may be performed in stable patients 1
  • Gallbladder perforation: Early cholecystectomy; percutaneous cholecystostomy for critically ill patients unfit for surgery 3

Percutaneous Drainage

• Where feasible, percutaneous drainage of abscesses and well-localized fluid collections is preferable to surgical drainage 1
• For periappendiceal abscesses, percutaneous image-guided drainage is recommended when available 1

Special Considerations

Relaparotomy Approach

• On-demand relaparotomy is recommended over planned relaparotomy for severe peritonitis 1
• Mandatory or scheduled relaparotomy is not recommended in the absence of intestinal discontinuity, abdominal fascial loss, or intra-abdominal hypertension 1

Antifungal Therapy

• Antifungal therapy is not routinely recommended for community-acquired peritonitis 1
• Consider antifungal therapy for hospital-acquired infections and in critically ill or severely immunocompromised patients 1

Duration of Antimicrobial Therapy

• Short-course (3-5 days) antibiotic therapy is recommended for perforated peptic ulcer peritonitis 1
• For other forms of peritonitis, continue antibiotics until clinical signs of infection and inflammatory markers normalize 1

Monitoring and Follow-up

• Monitor for resolution of peritonitis through clinical improvement and normalization of inflammatory markers 1
• If no improvement after 2 days of antibiotic treatment, consider antibiotic failure, resistant organisms, or secondary peritonitis 1
• Carefully monitor for complications such as intra-abdominal abscesses, sepsis, and organ dysfunction 1

Pitfalls to Avoid

• Delaying antimicrobial therapy in suspected peritonitis
• Using potentially nephrotoxic antibiotics (e.g., aminoglycosides) as empirical therapy 1
• Failing to achieve adequate source control
• Not considering resistant organisms in patients with healthcare exposure or recent antibiotic use
• Overlooking the need for antifungal therapy in high-risk patients

Remember that early diagnosis, prompt surgical intervention, appropriate antimicrobial therapy, and adequate resuscitation are the cornerstones of successful management of peritonitis.