Evaluation and management of secondary peritonitis - adapted from the Annals of Surgery 1996;224:10-8 - Tips from Other Journals

Peritonitis is defined as inflammation of the peritoneum from any cause. This includes localized inflammatory reactions caused by way of trauma or chemicals as well as intra-abdominal infection caused through microorganisms and their toxins. Secondary peritonitis includes a large variety of pathologic conditions ranging from local vexed questions such as gangrenous appendicitis to devastating disease similar as diffuse postoperative peritonitis resulting from dehiscence of a gastroduodenal anastomosis. Mortality is related mainly to the severity of the patient's systemic replication and premorbid reserves. Wittmann and colleagues reviewed passing from hand to hand literature to provide up-to-date information upon the management of secondary peritonitis.

The personality of obligate anaerobes, or a mixed flora, glance ats secondary peritonitis. The number and patterns 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 reduc to the microorganisms that survive well outside their natural environment. These microorganisms include endotoxin-generating facultative anaerobes similar as Escherichia cold and obligate anaerobes as it was as Bacteroides fragilis. These bacteria act in synergy to give rise to an abscess.

Timely therapeutic management of peritonitis is privationed to abort the self-perpetuating systemic inflammatory answer 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 to such a degree that the patient's defences, along with supportive antibiotics, allow resolution of inflammation.

The authors close that operative therapy and supportive antibiotics are appropriate in secondary peritonitis. Third-generation cephalosporins of the like kind as cefotaxime, ceftizoxime and ceftriaxone are effective against all strains of E hyemal and do not induce resistance. The possible carriage of obligate anaerobes requires the addition of metronidazole or clindamycin to the treatment regimen. The active mingle of cilastatin-imipenem is an effective single-drug therapy on the contrary should be reserved as a second-line agent for the nosocomially altered image of postoperative peritonitis. Intraoperative refinements 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" appears 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 onset and maintain adequate tissue oxygenation To treat bacteria not eliminated by way of surgery with antibiotics To support failing organ methods To provide adequate nutrition

Operative treatment Principle 1 (repair): curb 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): hinder or treat persistent and returning infection or verify both repair and purge

From Wittmann DH Schein M Condon RE Management of secondary peritonitis. Ann Surg 1996224: 10-8 Used with permission.

COPYRIGHT 1996 American Academy of Family Physicians

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