Therapeutics ID Bergman Flashcard

Peritonitis

  • Acute inflammatory response of peritoneal lining
  • Caused by:

microorganisms

chemicals

irradiation

foreign-boyd injury

Abcess

  • Purulent collection of fluid
  • Separated from surrounding tissue
  • Contains:

necrotic debris

bacteria

inflammatory cells

 

Primary Peritonitis: Classification

  • Often spontaneous
  • Bacteria comes from outside of peritoneum — through bloodstream or instrumentation
  • Usually caused by single organism

 

Primary Peritonitis: Causes/Risk Factors

  • Alcoholic cirrhosis
  • Continuous ambulatory peritoneal dialysis

Secondary Peritonitis: Classification

  • Most common
  • Infectious organism comes from within the abdominal cavity (GI flora)
  • Usually polymicrobial

Secondary Peritonitis: Causes/Risk Factors

  • Perforation (stomach, small or large bowel, urinary bladder, appendix, gallbladder, diverticula)
  • Post-Operative (peritoneal contamination)
  • Post-Traumatic (blunt or penetrating)

Tertiary Peritonitis: Classification

  • Occurs in critically ill patients
  • Persists or recurs at least 48 hrs after completion of adequate treating for primary or secondary peritonitis
  • Need to consider less common and multi-drug resistant bacteria and fungal pathogens

Tertiary Peritonitis: Causative Pathogens

  • Candida
  • VRE
  • Pseudomonas
  • Serratia
  • MRSA

Pathophysiology of Perotinitis

Bacterial Invasion

Peritonitis

Ileus/3rd spacing

Sepsis/Septic Shock

End organ damage

Death

Cholangitis/Cholecystitis: Defintions

  • Inflammation of biliary tract and/or gallbladder
  • Caused by:

cholelithiasis (gall stones)

cancer and strictures

Cholangitis/Cholecystitis: Signs/Symptoms

  • Fever
  • Leukocytosis
  • Right Upper Quadrant pain
  • N/D
  • AST/ALT
  • Bilirubin
  • ALP
  • Amylase

Cholangitis/Cholecystitis: Pathogens

  • Klebsiella
  • Enterobacter
  • E. coli
  • Proteus
  • Enterococcus
  • Anaerobes (Bacteroides fragilis)

Treatment for Cholangitis/Cholecystitis

  • Drain biliary tree or gall bladder
  • Culture the drainage, tissue, and blood
  • Antibiotics if gallbladder not removed and refine when culture and sensitivity come back
  • Provides supportive treatments for blood pressure, pain, and nausea

Duration of Treatment for Cholangitis/Cholecystitis

  • Treat for 2 days after symptoms absent — do not treat longer than 5-7 days if possible
  • Stop the antibiotics after gallbladder is removed unless there is perforation or gangrene

Treatment of Mild to Moderate Cholangitis/Cholecystitis

Gentamicin + ampicillin

OR

Fluoroquinolone

OR

3rd or 4th Gen Cephalosporin

+

metronidazole or clindamycin

 

OR

 

Ampicillin/Sulbactam

 

OR

 

Ertapenem

Treatment of Severe Cholangitis/Cholecystitis

3rd or 4th Cephalosporin

+

metronidazole or clindamycin

 

OR

 

Piperacillin/Tazobactam

 

OR

 

Imipenem or Meropenem

Primary Peritonitis: Signs and Symptoms

  • Fever
  • Leukocytosis
  • abdominal pain
  • N/V
  • AST/ALT
  • decreased bowel sounds

Primary Peritonitis: Treatment

  • Surgery/drainage (rare)
  • Culture blood, paracentesis fluid
  • Antibiotics
  • Supportive treatment, especially fluids
  • Narrow antibiotic coverage
  • Treat 2 days after symptoms are absent = 5-7 days –>longer to peritoneal dialysis

Primary Peritonitis associated with hepatic disease and cirrhosis: Pathogens

  • Enteric G-
  • Anaerobes (rare)
  • Enterococcus
  • Streptococcus (possible viridans infection)

 

Primary Peritonitis associated with hepatic disease and cirrhosis: Antibiotics

  • 3rd Gen Cephalosporins
  • Piperacillin/Tazobactam
  • Ampicillin/Sulbactam
  • Fluoroquinolones

If ESBL (E. coli, Klebsiella), use carbapenems

Primary Peritonitis associated with peritoneal dialysis: Pathogens

  • Staph. aureus
  • Staph. epidermidis
  • G- rods (occasionally) — G- enterics, rarely Non-enteric
  • Candida

Primary Peritonitis associated with peritoneal dialysis: Intraperitoneal Therapy

Intraperitoneal Therapy Preferred

 

Antibiotics dissolved in dialysate

 

Vancomycin sol’n

+

Ceftazidime sol’n or Gentamicin sol’n

;

Other regimens possible

;

;

Primary Peritonitis associated with peritoneal dialysis: Empiric Antibiotics

  • Vancomycin plus Ceftazidime
  • If MRSA not identified, switch Vancomycin with:

Nafcillin

Oxacillin

Cefazolin

Secondary Peritonitis: Signs/Symptoms

Develops acutely

  • Fever
  • Leukocytosis with left shift
  • Abdominal pain
  • Abdominal guarding or rigidness
  • N/V
  • Decreased bowel sounds
  • Tachycardia

;

Secondary Peritonitis: Treatment

  • Surgical repair and excision
  • Culture blood and peritoneal fluid
  • Treat with antibiotics
  • Supportive treatment such as fluids
  • Narrow antibiotic therapy if possible

Remember: secondary peritonitis is always polymicrobial and anaerobes might not grow on culture

;

Secondary Peritonitis: Pathogens

  • Enteric G-
  • Anaerobes (Bacteroides fragilis)
  • G+ (Enterococcus, Streptococcus)
  • Non-Enteric G- (P. aeruginosa)

Moderate-Severe Secondary Peritonitis: Antibiotics

  • Piperacillin/Tazobactam
  • Carbapenems
  • Tigecycline
  • 3rd or 4th Gen Cephalosporin + metronidazole or clindamycin

Secondary Peritonitis: Duration

Treat for 2 days after asymptomatic — limit to 5-7 days if possible

Blunt or sharp trauma — if antibiotics initiated within 3-4 hrs, treat 2-3 days

 

Appendicitis:

1 dose antibiotic if only inflammed and removed intact

Treat 5-7 days if ruptured or gangrenous appendix

Secondary and Tertiary Peritonitis: Candida Infection Treatment

  • Fluconazole
  • Echinocandin or Amphotericin B if life-threatening

Secondary and Tertiary Peritonitis: With No Improvement
Consider anti-staphylococcal and/or VRE coverage
Abscesses: Signs/Symptoms

  • Fever
  • Leukocytosis with left shift
  • Abdominal pain
  • Symptoms are not always persistent
  • Can be places other than abdomen (lung, brain, skin)

Abscesses: Treatment

  • Drain the abscess
  • Culture blood and drainage
  • Antibiotics
  • Pre-drainage — metronidazole or clindamycin
  • Post-drainage — beta-lactams, don’t use aminoglycosides
  • Supportive treatment with fluids
  • Treat for at least 7 days

Abscesses: Pathogens

  • ALWAYS AN ANAEROBE +
  • G- Enterics

OR

  • G+ (Enterococcus, Streptococcus)

If above the diaphragm, most likely G+ mouth flora

Abscesses: Antibiotics

Treat the same as secondary peritonitis

 

  • Ampicillin/Sulbactam
  • Fluoroquinolone + Metronidazole or Clindamycin
  • Piperacillin/Tazobactam
  • Carbapenem
  • Tigecycline
  • 3rd or 4th Gen Cephalosporin + Metronidazole or Clindamycin

Abscesses: Monitoring

Monitor for improvement or treatment failure

 

Improving:

resolution of fever

hemodynamic stability

absence or decline in abdominal pain

lab value improvement of WBC, LFT, and Bilirubin

Return or improvement of GI function

 

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