Intra-abdominal Infections
what is primary peritonitis
(aka spontaneous bacterial peritonitis - SBP) Infection in peritoneal cavity without an evident cause
what areas of normal flora have the most bacteria (aerobes and anarobes)
(most to least) Fallopian tubes Colon distal ileum proximal small bowel stomach biliary tract
what are the common secondary peritonitis organisms
(usually polymicrobial) Grm (-): *E. coli* Enterobacter Klebsiella Proteus Grm (+) : *Enterococcus* Streptococcus Staphylococcus Anaerobic: *bacteroides* clostridium Fungi
what are the signs and symptoms of secondary peritonitis
*acute onset* Generalized abdominal pain Tachypnea, tachycardia, nausea & vomiting Fever Hypotension & shock Decreased urine output Hypovolemia --> Sepsis
what are the main treatment steps in any peritonitis
1. Drainage if necessary 2. hemodynamic resuscitation 3. antimicrobial therapy 4. Nutrition Treatment requires hospitalization
what are the secondary peritonitis community acquired treatment caveats
1st and 2nd gen ceph AND FQ have high rates of resistance Need to cover for enterococcus faecalis in HIGH risk (Carbapenems are NOT first line)
how many days of antimicrobial treatment is sufficient for most intraabdominal infections
4-7 days
what is secondary peritonitis
A focal disease process is evident - can identify what caused the peritonitis. Perforation of GI tract Postoperative Posttraumatic APPENDICITIS
in a physical exam what might you notice for secondary peritonitis
Abdominal guarding "Board-like abdomen" Distension and tenderness Faint bowel sounds
what is peritonitis
Acute inflammatory response of the peritoneal lining
How do you assess intravascular volume for hemodynamic resuscitation?
BP, HR, UO, CVP (treat towards Sepsis goals)
from where do bacteria come from (in primary peritonitis)
Blood, lymphatics Catheters/ dialysis Fallopian tubes
what are the combination agents for Secondary Peritonitis: Community Acquired in mild-moderate
Cefazolin OR cefuroxime Ceftriaxone OR cefotaxime Ciprofloxacin OR levofloxacin WITH Metronidazole/ clindamycin
what are the combination agents for Secondary Peritonitis: Community Acquired high risk
Cefepime OR ceftazidime, Ciprofloxacin OR Levofloxacin WITH Metronidazole/ Clindamycin
what are the single agent Secondary Peritonitis: Community Acquired for mild-moderate
Cefoxitin Ertapenem Moxifloxacin Tigecycline Ticarcillin-clavulanic acid
what antibiotics should be avoided in what organisms due to resistance
E. Coli: ampicillin/sulbactam, FQ B. fragilis: clindamycin, cefotetan
what are the common pathogens in primary peritonitis for peritoneal dialysis
Grm (+)/ *skin bugs* : S. Epidermidis S. Aureus streptococci diptheroids
what are the common pathogens in primary peritonitis for cirrhosis
Grm (-): *E. Coli * Haemophilus pneumoniae Klebsiella Anaerobes S. pneumonia, Pseudomonas
what are the common pathogens in primary peritonitis for children
Group A strep E.coli *Strep Pneumo Bacteroides*
what are the single agent Secondary Peritonitis: Community Acquired for high risk
Imipenem-cilastatin Meropenem OR doripenem Piperacillin-tazobactam
what is tertiary perionitis
Infection that persists or recurs > 48 hrs after management of primary or secondary peritonitis
what is the treatment for prophylaxis of primary and secondary
Norfloxacin, ciprofloxacin, Bactrim (tmp/smx)
what are common causes of primary peritonitis
Peritoneal dialysis cirrhosis with ascites (Nephrotic syndrom)
what are the duration times for primary and secondary peritonitis
Primary peritonitis Cirrhosis and ascites: 5 days Peritoneal dialysis: 14 days Secondary peritonitis 4-7 days unless reason to continue longer
when is drainage needed in primary, secondary, and abscess
Primary: usually not required Secondary: surgical correction of underlying cause Abscess: ALWAYS drain
what is a abscess in peritonitis
Result from chronic inflammation Forms in weeks to years Localized incomplete bacterial elimination Fibrinous capsule
what are the 6 common causes of ascites
Severe liver damage CHF Pancreatitis Dialysis Portal vein thrombosis Malignancies
how do you treat secondary Peritonitis: Health Care-Associated
Treat as would high-severity community acquired with enterococcus faecalis coverage
what are the treatment options for Secondary Peritonitis: Health Care-Associated
Treat like high-severity community acquired with enterococcus faecalis coverage Vanco or Aminopenicillins (Amox and Amp)
who needs prophylaxis for primary
ascites + active upper GI bleed (both) ascitic fluid protein <1.5 g/dL AND at least 1 of the following factors: SCr ≥ 1.2 mg/dL BUN ≥ 25 mg/dL Serum Na ≤ 130 mEq/L Child-Pugh score ≥ 9 points, with bilirubin ≥ 3 mg/dL
what are the presentations of primary peritoneal
develops over days to weeks Signs: Loss of appetite, bloating, nausea, vomiting, abdominal tenderness Low grade fever Hypoactive bowel sounds
what are the common causes of secondary peritonitis (and abscesses)
perforation of GI ischemia obstruction postop/ post trauma ... *Appendicitis* ... diverticulitis IBS Biliary tract infection necrotizing pancreatitis
what are the primary agents for primary peritonitis from peritoneal dialysis
use: Vancomycin/ 1st gen Ceph PLUS Aminoglycoside/ 3rd gen Ceph treatment of: S. Epidermidis, S. Aureus, streptococci, diptheroids
what are the primary agents for primary peritonitis from cirrhosis (adults)
use: Cefotaxime/ Ceftriaxone (any 3rd Ceph Gen) treatment of : E. Coli, H. pneumo, Klebsiella, Anaerobes: S. pneumo, Pseudomonas