Therapeutics ID Bergman Flashcard


  • Acute inflammatory response of peritoneal lining
  • Caused by:




foreign-boyd injury


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

necrotic debris


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


Ileus/3rd spacing

Sepsis/Septic Shock

End organ damage


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
  • 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




3rd or 4th Gen Cephalosporin


metronidazole or clindamycin









Treatment of Severe Cholangitis/Cholecystitis

3rd or 4th Cephalosporin


metronidazole or clindamycin








Imipenem or Meropenem

Primary Peritonitis: Signs and Symptoms

  • Fever
  • Leukocytosis
  • abdominal pain
  • N/V
  • 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:




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



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

  • G- Enterics


  • 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



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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