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Peritoneumadhesion formation in trauma of, 263,263f visceral, 1041Peritonitis, 149–150duration of antibiotic therapy in, 146spontaneous bacterial

in cirrhosis, 129liver transplantation in, 34in transplantation procedures, 329

!icrobial contamination of the peritoneal cavity is termed peritonitisor intra-abdominal infection, and is classi"ed accordin#to etiolo#y$ Primary microbial peritonitis occurs %hen microbesinvade the normally sterile con"nes of the peritoneal cavity viahemato#enous dissemination from a distant source of infection or direct inoculation$ &his processis more common amon# patients%ho retain lar#e amounts of peritoneal 'uid due to ascites, andamon# those individuals %ho are bein# treated for renal failure

via peritoneal dialysis$ &hese infections invariably are monomicrobialand rarely re(uire sur#ical intervention$ &he dia#nosis isestablished based on identi"cation of ris) factors as noted previously,physical e*amination that reveals di+use tenderness and#uardin# %ithout localied "ndin#s, absence of pneumoperitoneumon an ima#in# study, the presence of more than 100-./sm, and microbes %ith a sin#le morpholo#y on ramsstain performed on 'uid obtained via paracentesis$ ubse(uentcultures typically %ill demonstrate the presence of #ram positiveor#anisms in patients under#oin# peritoneal dialysis$ npatients %ithout this ris) factor or#anisms can include E. coli,K. pneumoniae, pneumococci, and others, althou#h manydi+erent patho#ens can be causative$ &reatment consists of administration of an antibiotic to %hich the or#anism is sensitive

often 14 to 21 days of therapy are re(uired$ 7emovalof ind%ellin# devices 8e$#$, a peritoneal dialysis catheter or aperitoneovenous shunt may be re(uired for e+ective therapyof recurrent infections$Secondary microbial peritonitis occurs subse(uent to contaminationof the peritoneal cavity due to perforation or severein'ammation and infection of an intra:abdominal or#an$ ;*amplesinclude appendicitis, perforation of any portion of the #astrointestinaltract, or diverticulitis$ <s noted previously, e+ectivetherapy re(uires source control to resect or repair the diseasedor#an d=bridement of necrotic, infected tissue and debris andadministration of antimicrobial a#ents directed a#ainst aerobes and anaerobes$5> &his type ofantibiotic re#imen should be chosenbecause in most patients the precise dia#nosis cannot be

established until e*ploratory laparotomy is performed, and themost morbid form of this disease process is colonic perforation,due to the lar#e number of microbes present$ < combination of a#ents or sin#le a#ents %ith a broad spectrum of activity can beused for this purpose conversion of a parenteral to an oral re#imen%hen the patients ileus resolves provides results similarto those achieved %ith intravenous antibiotics$ ;+ective sourcecontrol and antibiotic therapy is associated %ith lo% failurerates and a mortality rate of appro*imately 5? to 6? inabilityto control the source of infection is associated %ith mortality

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#reater than 40?$59

 &he response rate to e+ective source control and use of appropriate antibiotics has remained appro*imately 0? to90? over the past several decades$60 Patients in %hom standardtherapy fails typically develop one or more of the follo%in#@an intra:abdominal abscess, lea)a#e from a #astrointestinalanastomosis leadin# to postoperative peritonitis, or tertiary 

(persistent) peritonitis$ &he latter is a poorly understood entitythat is more common in immunosuppressed patients in %homperitoneal host defenses do not e+ectively clear or se(uesterthe initial secondary microbial peritoneal infection$ !icrobessuch as Enterococcus faecalis and faecium, Staphylococcusepidermidis, Candida albicans, and Pseudomonas aeruginosacommonly are identi"ed, typically in combination, and theirpresence may be due to their lac) of responsiveness to the initialantibiotic re#imen, coupled %ith diminished activity of hostdefenses$ Anfortunately, even %ith e+ective antimicrobial a#enttherapy, this disease process is associated %ith mortality ratesin e*cess of 50?$61

Bormerly, the presence of an intra:abdominal abscessmandated sur#ical ree*ploration and draina#e$ &oday, the vast maCority of such abscesses can bee+ectively dia#nosed viaabdominal computed tomo#raphic 8/& ima#in# techni(uesand drained percutaneously$ ur#ical intervention is reservedfor those individuals %ho harbor multiple abscesses, those %ithabscesses in pro*imity to vital structures such that percutaneousdraina#e %ould be haardous, and those in %hom an on#oin#source of contamination 8e$#$, enteric lea) is identi"ed$ &henecessity of antimicrobial a#ent therapy and precise #uidelinesthat dictate duration of catheter draina#e have not been established$< short course 83 to days of antibiotics that possessaerobic and anaerobic activity seems reasonable, and most practitionersleave the draina#e catheter in situ until it is clear thatcavity collapse has occurred, output is less than 10 to 20 md,

no evidence of an on#oin# source of contamination is present,and the patients clinical condition has improved$