Introduction
Incidence of peritonitis
Microbiology of peritonitis
Pathogenesis
Risk factors associated with peritonitis and preventive measures
Presentation and diagnosis
Management of peritonitis
General guidelines
Antibiotics | Continuous therapy | Intermittent therapyb
| |
---|---|---|---|
Loading dosea
| Maintenance dose | ||
Glycopeptides | |||
Vancomycin | 1000 mg/L | 25 mg/L | 30 mg/kg q 5–7 days |
Teicoplaninc
| 400 mg/L | 20 mg/L | 15 mg/kg q 5–7 days |
Cephalosporins | |||
Cefazolin/Cephalothin | 500 mg/L | 125 mg/L | 15 mg/kg q 24 h |
Cefuroxime | 200 mg/L | 125 mg/L | 15 mg/kg q 24 h |
Cefotaxime | 500 mg/L | 250 mg/L | 30 mg/kg q 24 h |
Ceftazidime | 250 mg/L | 125 mg/L | 15 mg/kg q 24 h |
Ceftizoxime | 250 mg/L | 125 mg/L | – |
Antifungals | |||
Amphotericin B | 1 mg/kg IV | 1 mg/kg/day IV | – |
Fluconazole | – | – | 3 – 6 mg/kg IP, IV or PO q 24–48 h (max. dose 200 mg) |
Flucytosine | 50 mg/kg IV or PO (max. dose 2.0 g) | 25–37.5 mg/kg PO/day (max. dose 1.0 g) | − |
Aminoglycosidesd
| |||
Amikacin | 25 mg/L | 12 mg/L | – |
Gentamicin | 8 mg/L | 4 mg/L | – |
Netilmicin | 8 mg/L | 4 mg/L | – |
Tobramycin | 8 mg/L | 4 mg/L | – |
Penicillinsd
| |||
Azlocillin | 500 mg/L | 250 mg/L | – |
Piperacillin | – | 250 mg/L | 150 mg/kg IV q 12 h |
Ampicillin | – | 125 mg/L | – |
Oxacillin | – | 125 mg/L | – |
Nafcillin | – | 125 mg/L | – |
Amoxicillin | 250–500 mg/L | 50 mg/L | – |
Quinolones | |||
Ciprofloxacin | 50 mg/L | 25 mg/L | – |
Combinations | |||
Ampicillin/Sulbactam | 1000 mg/L | 100 mg/L | – |
Imipenem/Cilastatin | 500 mg/L | 200 mg/L | – |
Trimethoprim/sulfamethoxazole | 320/1600 mg/L | 80/400 mg/L | – |
Others | |||
Clindamycin | 300 mg/L | 150 mg/L | – |
Metronidazole | – | – | 35–50 mg/kg/day PO in 3 doses |
Rifampin | – | – | 20 mg/kg/day PO (max. dose 600 mg/day) |
Aztreonam | 1000 mg/L | 250 mg/L | – |
Antibiotic therapy
-
Gram-positive peritonitis. The empiric use of ceftazidime should be discontinued. For methicillin-sensitive staphylococci, the first generation cephalosporin should be continued or should replace the empiric glycopeptide. For patients with methicillin-resistant staphylococci, a glycopeptide (vancomycin or teicoplanin) should be continued or should replace the first-generation cephalosporin. Clindamycin is a satisfactory alternative for those who do not tolerate glycopeptide antibiotics. Ampicillin is a suitable monotherapy for peritonitis caused by enterococci and streptococci and can be replaced with clindamycin or a glycopeptide if organisms are resistant to ampicillin. Treatment duration should be 2 weeks for all organisms except S. aureus, for which therapy should be 3 weeks [11].
-
Gram-negative peritonitis. Upon culture of a single Gram-negative organism, the first-generation cephalosporin or glycopeptide should be discontinued and ceftazidime continued if the organism is sensitive to ceftazidime and the patient is responding well clinically. However, if the organism belongs to the Pseudomonas/Stenotrophomonas genus, a second antibiotic with synergistic activity (e.g. an aminoglycoside) should be added. If multiple Gram-negative organisms or anaerobic bacteria are grown, metronidazole should be added and the patient should be investigated for intra-abdominal pathology. The recommended duration of treatment is 3 weeks for Pseudomonas/Stenotrophomonas species, multiple organisms, and/or anaerobic organisms, and 2 weeks for other single Gram-negative organisms [11].
-
Culture-negative peritonitis. In cases where the culture remains sterile and the patient’s clinical condition is improving, combined empiric therapy should be continued for 2 weeks [11]. However, prolonged therapy with an aminoglycoside is discouraged because of the concern for toxicity.