Treatment of Peritonitis
The recommended treatment for peritonitis includes prompt surgical source control, broad-spectrum antibiotics, and appropriate fluid resuscitation, with surgical intervention being the cornerstone of management for diffuse peritonitis. 1, 2
Initial Management
- Immediate fluid resuscitation should be initiated to enhance visceral perfusion and address volume depletion, which is common in patients with peritonitis 1, 2
- Broad-spectrum antibiotics should be administered as soon as possible, ideally within 1 hour for patients with septic shock 1, 2
- Empiric antibiotic therapy should target a mixture of Gram-negative, Gram-positive, and anaerobic bacteria, based on the polymicrobial nature of peritonitis 2
Surgical Management
- Emergency surgical intervention should be performed as soon as possible in patients with diffuse peritonitis, even if ongoing measures to restore physiologic stability need to be continued during the procedure 1, 2
- The primary goals of surgery are to drain infected foci, control ongoing peritoneal contamination, and restore anatomic and physiological function 1, 2
- The specific surgical approach depends on the cause of peritonitis:
- For perforated diverticulitis with diffuse peritonitis, Hartmann's procedure is recommended in critically ill patients 1, 2
- For perforated peptic ulcer, simple closure with or without omental patch is appropriate for small perforations 1, 2
- For small bowel perforation, resection with primary anastomosis is preferred when appropriate 1, 2
Antibiotic Therapy
Community-Acquired Peritonitis
- For non-critically ill, immunocompetent patients with adequate source control:
For Patients with High Risk of ESBL-Producing Enterobacterales
For Septic Shock
- One of the following antibiotics is recommended:
For Patients with Beta-Lactam Allergy
- Eravacycline (1 mg/kg q12h) or tigecycline (100 mg loading dose, then 50 mg q12h) 2
Duration of Antibiotic Therapy
- For patients with adequate source control, a short course (3-5 days) of antibiotic therapy is recommended 2
- For immunocompromised or critically ill patients with adequate source control, antibiotic therapy up to 7 days is recommended, based on clinical conditions and inflammation indices 2
- Patients who have ongoing signs of infection or systemic illness beyond 7 days of antibiotic treatment warrant a diagnostic investigation 2
Special Considerations
Secondary Bacterial Peritonitis
- If secondary bacterial peritonitis is suspected, imaging tests such as abdominal computed tomography should be performed 2
- Tests for ascitic total protein, lactate dehydrogenase, glucose, Gram stain, carcinoembryonic antigen, and alkaline phosphatase help differentiate secondary bacterial peritonitis from spontaneous bacterial peritonitis 2
Fungal Peritonitis
- Antifungal therapy is recommended for hospital-acquired infections and in patients who are critically ill or severely immunocompromised 2
- For community-acquired fungal infection, antifungal therapy should be reserved for clinically severe cases 2
Common Pitfalls to Avoid
- Delaying surgical intervention while attempting complete physiologic stabilization increases mortality 1, 5
- Inappropriate selection of surgical approach based on patient condition (e.g., not using more conservative approaches like Hartmann's procedure for unstable patients) 1
- Prolonged courses of broad-spectrum antibiotics in patients with persistent signs of inflammation without searching for extra-abdominal and intraperitoneal sources of new infection 6
- Failure to maintain adequate antimicrobial coverage during the perioperative period 1, 3
Monitoring and Follow-up
- On-demand re-laparotomy is recommended for patients with severe peritonitis, as it streamlines healthcare resources and reduces overall medical costs 2
- Open abdomen may be a viable option for treating physiologically deranged patients with ongoing sepsis, facilitating subsequent exploration and control of abdominal contents, and preventing abdominal compartment syndrome 2