Home Intra-abdominal infections Post-operative peritonitis

Post-operative peritonitis

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DIAGNOSIS

Clinical signs and symptoms
• Fever
• Abdominal pain
• Abdominal tenderness

The atypical clinical presentation may be responsible for a delay in diagnosis and reintervention or reoperation.

Laboratory markers
• White blood cell
• C-reactive protein
• PCT

Imaging
• CT
• US

Imaging findings
• Signs of intestinal perforation (extraluminal gas, intra-abdominal fluid)
• Post-operative abscess

TREATMENT

Localised abscess
Percutaneous drainage and antibiotic therapy for 3-5 days.
Antibiotics and drainage may be the optimal means of treating post-operative localized intra-abdominal abscesses when there are no signs of generalized peritonitis. Small abscesses can be treated by antibiotics alone.

Diffuse peritonitis
Early surgical source control and antibiotic therapy for 5-7 days.
Procalcitonin can help to guide antibiotic therapy.

Empiric antibiotic regimens. Normal renal function
In patients with no risk for multidrug resistant organism
One of following antibiotics
Piperacillin/Tazobactam 4.5 g 6-hourly
Tigecycline 100 mg initial dose, then 50 mg 12-hourly (Carbapenem sparing strategy)
Meropenem 1 g 8-hourly +/- Ampicillin 2 g 6-hourly (critically ill patients)
Doripenem 500 mg 8-hourly +/- Ampicillin 2 g 6-hourly (critically ill patients)
Imipenem/Cilastatin 500 mg 6-hourly (critically ill patients)
+/-
In patients at high risk for invasive candidiasis
Fluconazole 800 mg LD then 400 mg 24-hourly
In patients with documented beta-lactam allergy consider use of antibiotic combinations with Amikacin 15–20 mg/kg 24-hourly

In patients with high risk for multidrug resistant organism
One of following antibiotics
Tigecycline 100 mg LD, then 50 mg 12-hourly (No active against Pseudomonas aeruginosa)
Eravacycline 1 mg/kg 12-hourly (No active against Pseudomonas aeruginosa)
+
Piperacillin/Tazobactam 4.5 6-hourly
or
In critically ill patients
one of the following antibiotics
Meropenem 1 g 8-hourly
Doripenem 500 mg 8-hourly
Imipenem/Cilastatin 500 mg 6-hourly
+
One of the following antibiotics
Vancomycin 25–30 mg/kg loading dose then 15–20 mg/kg/dose 8-hourly
Teicoplanin 12 mg/kg 12-hourly times 3 loading doses then 12 mg/kg 24-hourly
+/-
In patients with high risk for invasive candidiasis
– In stable patients
Fluconazole 800 mg LD then 400 mg 24-hourly

– In unstable patients
one of the following antifungal agents
caspofungin 70 mg LD, then 50 mg daily
Anidulafungin 200 mg LD, then 100 mg daily
Micafungin 100 mg daily
Amphotericin B Liposomal 3 mg/kg daily

– In patients with suspected or proven infection with MDR (non-metallo-beta-lactamase-producing) Pseudomonas aeruginosa consider use of antibiotic combinations with Ceftolozane /Tazobactam.

– In patients with suspected or proven infection with carbapenemase-producing Klebsiella pneumoniae and MDR (non-metallo-beta-lactamase-producing) Pseudomonas aeruginosa consider use of antibiotic combinations with Ceftazidime/Avibactam.

– In patients with suspected or proven infection with vancomycin-resistant enterococci (VRE) including patients with previous enterococcal infection or colonization, immunocompromised patients, patients with long ICU stay, or recent Vancomycin exposure
One of the following antibiotics
Tigecycline 100 mg LD, then 50 mg 12-hourly
Linezolid 600 mg 12-hourly

In patients with documented beta-lactam allergy consider use of antibiotic combinations with Amikacin 15–20 mg/kg daily.