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Pathophysiology

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(J Chemother 2009;21[Suppl]1:5)

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  • Caused by entry of bacteria into peritoneal or retroperitoneal cavities; may be dispersed or restricted to abscesses
  • Peritonitis classified as primary, secondary, or tertiary
  • Primary local humoral & cellular response to peritoneal bacteria is followed by widespread inflammation of peritoneal lining if infectious process not contained → mediated via cytokine release → fluid shifts deplete intravascular volume & hypovolemic shock
  • Bacteria translocate to bloodstream through inflamed peritoneum→ results in septic shock
  • Abscesses may form if peritoneal contamination is localized but bacteria not fully eradicated
  • Pharmacotherapy is aimed to restore intravascular volume & treat causative microorganisms

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Table 32-1 Pathophysiology of Primary, Secondary, & Tertiary Peritonitis
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(see Ch 9)

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Diagnosis & Evaluation

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(Dig Dis Sci 2008;53:2585)

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  • Classification
    • Community-acquired: mild-to-moderate severity or high severity (APACHE II score >15, advanced age, organ dysfunction, low albumin level, malignancy, diffuse peritonitis, inability to achieve source control)
    • Healthcare-associated
  • Causative Organisms
    • Polymicrobial: generally enteric gram-negative aerobic (esp. Escherichia coli) & anaerobic bacilli (esp. Bacteroides spp.) & enteric gram-positive streptococci
    • Healthcare-associated, particularly tertiary peritonitis cases, caused by resistant gram-negatives: nonlactose fermenters (Pseudomonas aeruginosa or Acinetobacter baumannii) or extended-spectrum β-lactamase–producing (ESBL) E. coli, Klebsiella, or Enterobacter spp.
    • Initiate empiric coverage for Enterococcus faecalis in high-severity community-acquired or healthcare-associated infections (especially with prior cephalosporin exposure or recent abdominal procedures) → use ampicillin, piperacillin-tazobactam, or vancomycin
    • Empiric coverage for vancomycin-resistant Enterococcus faecium only if very high-risk for this organism (liver transplant recipient or colonization with vancomycin-resistant E. faecium)
    • Antifungal therapy for patients with severe community-acquired or health­care-associated infection if Candida grown from intra-abdominal cultures
    • Empiric anti-MRSA coverage for colonized patients with healthcare-associated infections or significant antibiotic exposure

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Clinica Pearl 32-1
  • Pertinent positive labs
    • Leukocytosis 15,000–20,000 WBC/mm3...

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