What is the recommended treatment for peritonitis?

Treatment of Peritonitis

Peritonitis requires immediate emergency surgical intervention combined with broad-spectrum antibiotics and aggressive fluid resuscitation, with surgery performed as soon as possible even while continuing resuscitative measures. 1, 2

Immediate Resuscitation and Stabilization

• Begin aggressive fluid resuscitation immediately to address volume depletion and enhance visceral perfusion, which is universally present in peritonitis patients 1, 2
• Administer broad-spectrum antibiotics within 1 hour for patients presenting with septic shock 1, 2
• Do not delay surgery for complete physiologic stabilization - resuscitative measures must continue concurrently during the surgical procedure, as delayed source control directly increases mortality 2

Empiric Antibiotic Selection

The choice of antibiotics depends on illness severity and risk factors:

Non-Critically Ill Patients with Adequate Source Control

• Piperacillin/tazobactam is the recommended first-line agent for immunocompetent patients 1
• Alternative options include cefoxitin or augmentin plus gentamicin for less severe cases 3

Critically Ill Patients or Septic Shock

• Meropenem, doripenem, or imipenem/cilastatin are recommended for patients in septic shock 1, 4
• Meropenem dosing: 1 gram IV every 8 hours for intra-abdominal infections 4
• These carbapenems provide coverage against the polymicrobial flora including Gram-negatives, Gram-positives, and anaerobes 1

High-Risk Patients

• For patients with risk of ESBL-producing Enterobacterales, use ertapenem or eravacycline 1
• Prior broad-spectrum antibiotic use between initial surgery and reoperation is the strongest risk factor for multidrug-resistant organisms (OR 5.1), requiring combination therapy with imipenem/cilastatin plus amikacin plus glycopeptide for 94-99% adequacy 5
• Add antifungal therapy (fluconazole) for hospital-acquired infections or in critically ill/severely immunocompromised patients 1

Surgical Management

Timing and Approach

• Perform emergency laparotomy immediately with goals to drain infected foci, control ongoing contamination, and restore anatomic function 1, 2
• The surgical approach must be tailored to the underlying pathology and patient stability 2

Specific Surgical Procedures

• For perforated diverticulitis with diffuse peritonitis in critically ill patients: Hartmann's procedure is the recommended approach 1, 2
• For perforated peptic ulcer or small bowel perforation: Simple closure with or without omental patch for small perforations; resection with primary anastomosis when appropriate 2
• For physiologically deranged patients with ongoing sepsis: Open abdomen may be necessary to facilitate subsequent exploration and prevent abdominal compartment syndrome 1

Relaparotomy Strategy

• Use on-demand relaparotomy rather than mandatory scheduled relaparotomy in the absence of intestinal discontinuity, fascial loss, or intra-abdominal hypertension 1, 2
• This approach streamlines resources and reduces costs while maintaining outcomes 1

Duration of Antibiotic Therapy

• For non-critically ill patients with adequate source control: 3-5 days of antibiotics post-operatively 1
• For immunocompromised or critically ill patients with adequate source control: up to 7 days 1
• Duration may extend to 14 days in severe nosocomial or tertiary peritonitis 3

Critical Pitfalls to Avoid

• Never delay surgery while attempting complete hemodynamic stabilization - this significantly increases mortality 2
• Ensure antimicrobial levels are maintained during surgery - may require additional dosing immediately preoperatively 2
• Do not use antibiotics alone without source control - drainage and surgical intervention are essential for treatment success 2
• Recognize that Enterococcus faecalis coverage becomes important in patients with organ failure or septic shock 3