Peritonitis is defined as inflammation of the peritoneum from any cause. This includes localized inflammatory reactions caused by trauma or chemicals as well as intra-abdominal infection caused by microorganisms and their toxins. Secondary peritonitis includes a large variety of pathologic conditions ranging from local problems such as gangrenous appendicitis to devastating disease such as diffuse postoperative peritonitis resulting from dehiscence of a gastroduodenal anastomosis. Mortality is related mainly to the severity of the patient's systemic response and premorbid reserves. Wittmann and colleagues reviewed current literature to provide up-to-date information on the management of secondary peritonitis.
The presence of obligate anaerobes, or a mixed flora, suggests secondary peritonitis. The number and types of bacteria increase progressively down the gastrointestinal tract. Following a breach in a bacteria-containing viscus, many different species of bacteria may be released. However, this inoculum is spontaneously reduced to the microorganisms that survive well outside their natural environment. These microorganisms include endotoxin-generating facultative anaerobes such as Escherichia cold and obligate anaerobes such as Bacteroides fragilis. These bacteria act in synergy to produce an abscess.
Timely therapeutic management of peritonitis is needed to abort the self-perpetuating systemic inflammatory response syndrome before the occurrence of advanced cellular injury, which can lead to multiple organ failure and death. The management principles for secondary peritonitis are noted in the accompanying table. Timely surgical intervention is critical to stop the inoculum of microorganisms so that the patient's defences, along with supportive antibiotics, allow resolution of inflammation.
The authors conclude that operative therapy and supportive antibiotics are appropriate in secondary peritonitis. Third-generation cephalosporins such as cefotaxime, ceftizoxime and ceftriaxone are effective against all strains of E. cold and do not induce resistance. The possible presence of obligate anaerobes requires the addition of metronidazole or clindamycin to the treatment regimen. The active compound of cilastatin-imipenem is an effective single-drug therapy but should be reserved as a second-line agent for the nosocomially altered spectrum of postoperative peritonitis. Intraoperative cultures are rarely helpful because they seldom influence the choice of antibiotics. The duration of antibiotic therapy has not been established because the exact time at which the transition from infection to "inflammation-only" occurs is uncertain. (Wittman DH, et al. Management of secondary peritonitis. Ann Surg 1996; 224:10 8.)
Management Principles of Peritonitis
Supportive measures To combat hypovolemia and shock and maintain adequate tissue oxygenation To treat bacteria not eliminated by surgery with antibiotics To support failing organ systems To provide adequate nutrition
Operative treatment Principle 1 (repair): Control the source of infection Principle 2 (purge): Evacuate bacterial inoculum, pus and adjuvants (peritoneal "toilet") Principle 3 (decompress): Treat abdominal compartment syndrome Principle 4 (control): Prevent or treat persistent and recurrent infection or verify both repair and purge
From Wittmann DH, Schein M, Condon RE. Management of secondary peritonitis. Ann Surg 1996,224: 10-8. Used with permission.
COPYRIGHT 1996 American Academy of Family Physicians
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