What is the treatment plan for a patient with suspected perforation peritonitis complicating enteric fever?

Treatment Plan for Suspected Perforation Peritonitis Complicating Enteric Fever

Patients with suspected perforation peritonitis from enteric fever require immediate emergency surgical intervention combined with aggressive fluid resuscitation and broad-spectrum antibiotics covering multidrug-resistant organisms, as delayed surgery significantly increases mortality. 1, 2

Immediate Preoperative Management

Fluid Resuscitation

• Begin rapid restoration of intravascular volume immediately upon diagnosis, as volume depletion is universal in peritonitis patients 1
• Continue resuscitative measures concurrently during surgical preparation—do not delay surgery for complete physiologic stabilization 1, 2
• For patients with septic shock, fluid resuscitation must start the moment hypotension is identified 1

Antimicrobial Therapy

• Initiate broad-spectrum antibiotics immediately, ideally within 1 hour for septic shock patients 1, 2
• For enteric fever perforations, use third-generation cephalosporins (ceftriaxone), fluoroquinolones (ciprofloxacin), or carbapenems (meropenem 1 gram IV every 8 hours), as multidrug-resistant Salmonella Typhi is common and resistant to chloramphenicol, ampicillin, and co-trimoxazole 3, 4
• Ensure coverage for Gram-negative bacteria (including resistant Salmonella), anaerobes (Bacteroides fragilis), and facultative organisms 1, 5
• Alternative regimens include piperacillin-tazobactam (3.375 grams IV every 4-6 hours) or meropenem combined with metronidazole 1, 3, 6
• Maintain adequate antimicrobial drug levels during the surgical procedure, which may require additional dosing just before incision 1

Diagnostic Confirmation

• Obtain CT scan if time permits, as it is more sensitive than plain radiographs for detecting free air and assessing perforation extent 1, 7
• Check white blood cell count and C-reactive protein 1, 7
• Blood cultures may be helpful in toxic-appearing or immunocompromised patients to guide antibiotic duration 1

Surgical Management

Timing and Approach

• Proceed to emergency laparotomy as soon as possible—diffuse peritonitis mandates immediate surgery even if physiologic stabilization is incomplete 1, 2
• The primary surgical goals are: drain infected foci, control ongoing peritoneal contamination, and restore bowel continuity when feasible 1, 2

Surgical Options for Ileal Perforation

• For single or few perforations with viable tissue: primary repair with or without omental patch 7, 8
• For multiple perforations (enteric fever commonly causes multiple perforations), extensive tissue damage, or hemodynamically unstable patients: resection with temporary loop ileostomy is preferred over primary anastomosis 7, 9, 8
• Loop ileostomy reduces postoperative complications (6.67% vs 20% leak rate with primary repair) and is only temporary, with closure typically at 6-8 weeks 8
• Perform thorough peritoneal lavage and drainage of infected collections 5

Critical Pitfall to Avoid

• Do not perform primary anastomosis in critically ill patients with multiple perforations, as leak rates are unacceptably high—use damage control surgery with ileostomy instead 2, 7, 8
• Delayed surgical intervention after failed conservative management significantly worsens outcomes and increases mortality 7, 4

Postoperative Management

Antibiotic Duration

• Continue antibiotics postoperatively for approximately 4-5 days if adequate source control was achieved 1
• Shorten antibiotic course as soon as physiological abnormalities resolve (normalization of fever, white blood cell count, and clinical improvement) 1
• Avoid prolonged empiric broad-spectrum antibiotics beyond 5-7 days, as this promotes multidrug-resistant organisms and tertiary peritonitis 10

Monitoring

• Perform serial clinical assessments every 3-6 hours monitoring for peritoneal signs (tenderness, rebound, guarding), fever, and vital signs 1
• Check laboratory values including white blood cell count, C-reactive protein, procalcitonin, and electrolytes daily 1
• Obtain CT scan at 5-7 days if clinical deterioration occurs or to exclude abscess formation before discharge 1

Additional Considerations

• Provide thromboprophylaxis during hospitalization given the high inflammatory burden 1
• Mandatory relaparotomy is not recommended unless intestinal discontinuity, inability to close fascia, or intra-abdominal hypertension develops 1, 2
• If ileostomy was performed, plan closure at 6-8 weeks once inflammation resolves and patient recovers 8

Special Considerations for Enteric Fever

• Enteric fever perforations frequently present with multiple (sometimes >20) ileal and cecal perforations, making primary repair inappropriate 9
• High mortality (53%) is associated with delayed diagnosis, inappropriate first-line antibiotics (chloramphenicol, ampicillin), and late surgical intervention 4
• Multidrug-resistant Salmonella Typhi is increasingly common, mandating third-generation cephalosporins or fluoroquinolones as first-line therapy 4