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Definition

Peritonitis defined as the inflammation of the peritoneum from any cause which lines abdominal cavity and the internal organs as a serosal membrane. Contrast to peritonitis, Intrabdominal infection is defined as the inflammation of peritoneum due to infectious cause.

Primary or Spontaneous Peritonitis

Primary peritonitis is defined as the infection of the peritoneal cavity which is spontaneous and often associated with liver disease and ascites. It is also known as spontaneous bacterial peritonitis.[1] Primary peritonitis lacks an identifiable anatomical derangement.[2]

Secondary Peritonitis

Secondary peritonitis is defined as the infection of the peritoneum due to spillage of organisms into the peritoneal cavity resulting from hollow viscus perforation, anastomotic leak, ischemic necrosis, or other injuries of the gastrointestinal tract.[3]

Tertiary Peritonitis

Tertiary peritonitis is defined as the persistant or recurrent intra-abdominal infection that occur in ≥48 hours following the successful and adequate surgical source control of primary or secondary peritonitis.[3][4][5]


Bacterascitis

Bacterascites is defined as the presence of culture positivity without increase in PMN count in the ascitic fluid.[6]

Historical Perspective

The first reports describing this entity appeared in the German and French literatures between 1907 and 1958. Spontaneous bacterial peritonitis was first described by Krencker in 1907 followed by Caroli in 1958 and Kerr and colleagues in 1963.[7][8] The term 'spontaneous bacterial peritonitis' was coined by Conn in 1964 to depict a syndrome of peritonitis and bacteremia in Laennec’s cirrhosis without an apparent cause of infection.[9]

Classification

Peritonitis is classified based on the etiology as follows:[10]

 
 
 
 
 
 
 
 
Peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary peritonitis
 
 
 
 
Secondary peritonitis
 
 
 
 
Tertiary peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Spontaneous peritonitis
❑ Peritonitis in patients with CAPD
❑ Tuberculous peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
❑ Peritonitis without evidence for pathogens
❑ Peritonitis with fungi
❑ Peritonitis with low-grade pathogenic bacteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute perforation peritonitis
❑ Gastrointestinal perforation
❑ Intestinal ischemia
❑ Pelviperitonitis and other forms
 
 
Postoperative peritonitis
❑ Anastomotic leak
❑ Accidental perforation and devascularization
 
 
Post-traumatic peritonitis
❑ After blunt abdominal trauma
❑ After penetrating abdominal trauma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pathogenesis

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patent with signs and symptoms suggestive of peritonitis
❑ Abdominal pain ± guarding or rebound
❑ Fever, leukocytosis
❑ Signs of sepsis (hypotension, tachycardia, etc.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peritonitis is diffuse
 
 
 
 
 
 
 
 
 
Peritonitis is localized
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate GI pathology and potential secondary peritonitis based on history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If negative Consider Primary Peritonitis
 
 
 
 
 
 
 
 
 
If positive
Suspect Secondary peritononitis
 
 
 
Secondary peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peritoneal dialysis
 
 
 
 
 
 
 
Ascites
 
 
 
 
 
 
Obtain flat and upright abdominal films
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drain peritoneal fluid and irrigate 2-3 times
 
 
 
 
 
 
 
Diagnostic paracentesis
 
 
 
 
 
 
Free air?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Send peritoneal fluid for Gram stain and culture, cell count with differential and pH
❑ Initiate general supportive care
Initiate empiric antibiotic coverage according to most likely pathogen
 
 
 
 
 
 
 
 
 
 
 
No free air under the diaphragm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monomicrobial Gram stain or culture
❑ Tailor antibiotics and continue for 7days
 
 
 
 
 
 
 
 
Polymicrobial Gram stain or culture or presence of bile or fecal material in peritoneal fluid
❑ Broaden antibiotic coverage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Condition resolved
 
 
 
 
 
 
 
Condition does not resolved:
❑ Re-culture,
❑ Adjust antibiotics
❑ Remove indwelling catheters
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue workup for:
❑ Cholecystitis, pancreatitis
❑ Diverticulitis, colitis, ileitis
❑ Pelvic inflammatory disease or other gynecologic causes
❑ Other non-GI causes
Tests include:
CT-scan
Abdominal ultrasound
Laboratory tests such as: Serum amylase, lipase, bilurubin, alk. phosphotase, lactate, urinalysis and beta-HCG, stool WBC and culture, Clostridium difficile toxin assay and others
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
← ← ← ←
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peritoneal abscess?
❑ No clear indications for operation?
❑ Drainable through percutaneous approach?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Indication for operation?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If YES
 
 
 
 
 
 
 
If NO
 
 
 
 
 
 
 
 
 
If YES
 
 
 
 
 
 
 
If NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Percutaneous drainage of abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
Depending on the severity of the disease, prepare patient for emergent laparotomy
Goals of operative approach
❑ Eliminate pathologic process
❑ Reduce bacterial contamination
❑ Provide adequate drainage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue conservative therapy and antibiotics until:
❑ Symptoms resolved
❑ Afebrile ≥ 48 hours
❑ Normal WBC count
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Condition resolved
 
 
 
 
 
 
 
 
 
 
 
Condition does not resolve:
❑ Persistent or new pathologic process?
❑ Tertiary peritonitis or abscess?
→ → → →
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
A01
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
A02
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
B01
 
 
 
 
 
 
 
 
 
B02
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
C01
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D01
 
 
 
 
 
 
 
 
 
D02
 
 
 
D03
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E01
 
 
 
 
 
 
 
E02
 
 
 
 
 
 
E03
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
F01
 
 
 
 
 
 
 
F02
 
 
 
 
 
 
F03
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
G01
 
 
 
 
 
 
 
 
 
 
 
G02
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
H01
 
 
 
 
 
 
 
 
H02
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
I01
 
 
 
 
 
 
 
I02
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
J01
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
K01
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
K02
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
L01
 
 
 
 
 
 
 
L02
 
 
 
 
 
 
 
 
 
L03
 
 
 
 
 
 
 
L04
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
M01
 
 
 
 
 
 
 
 
 
 
 
 
 
M02
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
N01
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
O01
 
 
 
 
 
 
 
 
 
 
 
O02
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Peritonitis can be regarded as the localized event after any trigger of inflammation similar to the systemic inflammatory response(SIRS).[11]

Primary peritonitis

As the primary disease (e.g. cirrhosis) progresses, gram negative bacteria increase in numbers in the gut.[12] Once bacteria reach a critical concentration in the gut lumen, they will translocate into the mesenteric lymphatic system because of the failure of the gut to contain bacteria and failure of the immune system to kill the virulent bacteria once they have escaped the gut result in bacteremia and endotoxinemia.

Secondary peritonitis develops perforation of intra abdominal organs when bacteria contaminate the peritoneum as a result of spillage from an intraabdominal viscus. The organisms found almost always constitute a mixed flora in which facultative gram-negative bacilli and anaerobes predominate, especially when the contaminating source is colonic.

Causes

Common Causes

Primary Peritonitis Secondary Peritonitis Tertiary Peritonitis
  • Cirrhosis with ascitis
  • Portal hypertension with ascitis
  • Renal failure patient with continuous ambulatory peritoneal dialysis (CAPD)
  • Ruptured gastric ulcer, appendicular abscess or diverticular abscess
  • Inflamatory bowel diseases such as chron's disease or ulcerative colitis with toxic megacolon
  • Pelvic inflamatory disease
  • Recent surgical procedures
  • Recent trauma to the abdomen (e.g. Stab injury or gun shot injury)
  • Previous history of severe antibiotic use
  • Treatment failure in patients with primary or secondary peritonitis

Epidemiology

SBP is the most frequent bacterial infection in cirrhosis, accounting for 10-30% of all reported bacterial infections in hospitalised patients.[13][14]

The prevalence of SBP in outpatient setting asymptomatically is low (< 3.5% ), but the prevalence increases to 8%-36% in the nosocomial setting.[15][16]

Mortality rate for the first episode of SBP in in-patient setting varies between 10-50%, depending upon the risk factors.[14][17] One-year mortality after a first episode of SBP has been reported to be 31% and 93%.

Diagnosis

Identification of risk factors and individualisation of timing and selection of prophylactic measures are the key to success without major development of resistant bacteria.[1]

Varient of Spontaneous bacterial peritonitis (SBP) Ascitic fluid analysis and other information
SBP culture postive
  • PMNs ≥250 cells/mm3 and culture positivity
  • Patients with cirrhosis and ascites in the presence or absence of symptoms and signs
Culture-negative neutrocytic ascites(CNNA) or culture-negative SBP
  • PMNs ≥250 cells/mm3 and culture negativity
  • Poor culture technique and prior antibiotics or low opsonic activity in ascitic fluid. Commonly encountered phenotype and requires antibiotic therapy
Monomicrobial bacterascites
  • PMNs <250 cells/mm3 and culture positivity
  • Ascitic fluid infection which may resolve spontaneously or progress to SBP. Similar mortality to SBP and should be treated the same
Other varieties of ascitic fluid infections Ascitic fluid analysis and other information
Polymicrobial bacterascites
  • PMNs <250 cells/mm3 and culture positivity
  • Needle perforation
Secondary peritonitis
  • PMNs ≥250 cells/mm3 and culture positivity
  • Intraperitoneal source of infection, e.g. diverticulitis


Treatment

Empirical treatment for peritonitis
Primary Peritonitis[18] Secondary Peritonitis[19] Peritonitis related to peritoneal dialysis[20]
  • Ceftriaxone 1gm IV Q12H x 5days
  • Penicillin allergic patients: Moxifloxacin 400mg IV/PO Q24H x 5days
  • Patient with serum creatinine >1mg/dl, BUN >30mg/dl or total bilurubi >4mg/dl should also receive Albumin25% 1.5g/kg on day 1 and 1gm/kg on day 3 (round to the nearest 12.5gm)

Duration: 5days

Mild or moderate secondary peritonitis

  • Ertapenem 1gm IV Q24H
  • Penicillin allergic patients: Ciprofloxacin 400mg IV Q12H + Metronidazole 500mg IV Q8H

Severe peritonitis or Immunocompromised patients

  • Piperacillin/ tazobactam 3.375gm IV Q6H
  • Penicillin allergic patient: Cefepime 1gm IV Q8H + Metronidazole 500gm IV Q8H
  • Severe PCN allergic patient: Vancomycin + Aztreonam 1gm IV Q8H or Ciprofloxacin 400mg IV Q8H + Metronidazole 500mg IV Q8H


Duration of empiric therapy depends on whether the peritonitis is complicated or uncomplicated:

Uncomplicated: Perforation is operated with in 12-24 hours

  • Duration of empiric therapy: 24-48

Complicated: Perforation is operated lately or necrotic/gangrenous appendix is developed.

  • Duration of empiric therapy: 4 days unless adequate source control is not achieved.

Mild or moderate secondary peritonitis
Intraperitoneal therapy is preferred

  • Anuric patient
    • Cefazolin 15mg/kg in one bag + Gentamicin 2mg/kg in one bag loading dose, then Gentamicin 0.6mg/kg in one bag Q24H
  • Patient with urine output > 100ml/day
    • Ceftazidime 1gm in one bag Q24H

Sever illness
Systemic therapy is preferred.

  • Initial dose: Vancomycin + Gentamicin 2mg/kg or Ceftazidime 1gm IV or Ciprofloxacin 400mg IV
  • Maintainance dose: dosage level depending on renal funtion

Duration: 10-14days

Empiric antifungal therapy
Emperical antifungal therapy is generally indicated in secondary peritonitis excepet if the patient has one of the following risk factors:
  • Esophageal perforation
  • Immunosuppression
  • Prolonged antacid therapy
  • Prolonged antibiotic therapy
  • Prolonged hospitalization
  • Persistant GI leak

If the patient is clinically stable and no history of prior long term azole therpy: Fluconazole 400-800 mg IV/PO Q24H

If the patient is clinically unstable or patient with history of prior long term azole therpy: Micafungin 100mg IV Q24H

Primary Peritonitis

The flora of primary peritonitis is typically monomicrobial.

Secondary Peritonitis

Treatment of secondary peritonitis depends on the etiological factor and effective therapy includes cause specific surgical intervention and adjunctive antibiotic therapy.[5]

Prevention

Prophylaxis is of crucial relevance when trying to improve survival.[1]

References

  1. 1.0 1.1 1.2 Wiest R, Krag A, Gerbes A (2012) Spontaneous bacterial peritonitis: recent guidelines and beyond. Gut 61 (2):297-310. DOI:10.1136/gutjnl-2011-300779 PMID: 22147550
  2. Mishra SP, Tiwary SK, Mishra M, Gupta SK (2014) An introduction of Tertiary Peritonitis. J Emerg Trauma Shock 7 (2):121-3. DOI:10.4103/0974-2700.130883 PMID: 24812458
  3. 3.0 3.1 Calandra T, Cohen J, International Sepsis Forum Definition of Infection in the ICU Consensus Conference (2005) The international sepsis forum consensus conference on definitions of infection in the intensive care unit. Crit Care Med 33 (7):1538-48. PMID: 16003060
  4. Evans HL, Raymond DP, Pelletier SJ, Crabtree TD, Pruett TL, Sawyer RG (2001) Tertiary peritonitis (recurrent diffuse or localized disease) is not an independent predictor of mortality in surgical patients with intraabdominal infection. Surg Infect (Larchmt) 2 (4):255-63; discussion 264-5. DOI:10.1089/10962960152813296 PMID: 12593701
  5. 5.0 5.1 Nathens AB, Rotstein OD, Marshall JC (1998) Tertiary peritonitis: clinical features of a complex nosocomial infection. World J Surg 22 (2):158-63. PMID: 9451931
  6. Castellote J, Girbau A, Maisterra S, Charhi N, Ballester R, Xiol X (2008) Spontaneous bacterial peritonitis and bacterascites prevalence in asymptomatic cirrhotic outpatients undergoing large-volume paracentesis. J Gastroenterol Hepatol 23 (2):256-9. DOI:10.1111/j.1440-1746.2007.05081.x PMID: 17683477
  7. CAROLI J, PLATTEBORSE R (1958) [Portocaval septicemia; liver cirrhosis & septicemia caused by colibacillus.] Sem Hop 34 (8/2):472-87/SP. PMID: 13543374
  8. KERR DN, PEARSON DT, READ AE (1963) INFECTION OF ASCITIC FLUID IN PATIENTS WITH HEPATIC CIRRHOSIS. Gut 4 ():394-8. PMID: 14084751
  9. CONN HO (1964) SPONTANEOUS PERITONITIS AND BACTEREMIA IN LAENNEC'S CIRRHOSIS CAUSED BY ENTERIC ORGANISMS. A RELATIVELY COMMON BUT RARELY RECOGNIZED SYNDROME. Ann Intern Med 60 ():568-80. PMID: 14138877
  10. Wittmann DH, Schein M, Condon RE (1996). "Management of secondary peritonitis". Ann Surg. 224 (1): 10–8. PMC 1235241. PMID 8678610.
  11. Marshall J, Sweeney D (1990) Microbial infection and the septic response in critical surgical illness. Sepsis, not infection, determines outcome. Arch Surg 125 (1):17-22; discussion 22-3. PMID: 2294878
  12. Guarner C, Runyon BA, Young S, Heck M, Sheikh MY (1997) Intestinal bacterial overgrowth and bacterial translocation in cirrhotic rats with ascites. J Hepatol 26 (6):1372-8. PMID: 9210626
  13. Fernández J, Navasa M, Gómez J, Colmenero J, Vila J, Arroyo V et al. (2002) Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology 35 (1):140-8. DOI:10.1053/jhep.2002.30082 PMID: 11786970
  14. 14.0 14.1 Pinzello G, Simonetti RG, Craxì A, Di Piazza S, Spanò C, Pagliaro L (1983) Spontaneous bacterial peritonitis: a prospective investigation in predominantly nonalcoholic cirrhotic patients. Hepatology 3 (4):545-9. PMID: 6862365
  15. Jeffries MA, Stern MA, Gunaratnam NT, Fontana RJ (1999) Unsuspected infection is infrequent in asymptomatic outpatients with refractory ascites undergoing therapeutic paracentesis. Am J Gastroenterol 94 (10):2972-6. DOI:10.1111/j.1572-0241.1999.01445.x PMID: 10520854
  16. Conn HO, Fessel JM (1971) Spontaneous bacterial peritonitis in cirrhosis: variations on a theme. Medicine (Baltimore) 50 (3):161-97. PMID: 4938274
  17. Nobre SR, Cabral JE, Gomes JJ, Leitão MC (2008) In-hospital mortality in spontaneous bacterial peritonitis: a new predictive model. Eur J Gastroenterol Hepatol 20 (12):1176-81. DOI:10.1097/MEG.0b013e32830607a2 PMID: 18941414
  18. Rimola A, García-Tsao G, Navasa M, Piddock LJ, Planas R, Bernard B et al. (2000) Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol 32 (1):142-53. PMID: 10673079
  19. Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al. (2010) Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Surg Infect (Larchmt) 11 (1):79-109. DOI:10.1089/sur.2009.9930 PMID: 20163262
  20. Piraino B, Bernardini J, Brown E, Figueiredo A, Johnson DW, Lye WC et al. (2011) ISPD position statement on reducing the risks of peritoneal dialysis-related infections. Perit Dial Int 31 (6):614-30. DOI:10.3747/pdi.2011.00057 PMID: 21880990