the Management and Prevention of Peritonitis

- Recommendations

Section 1: Diagnosis of peritonitis:

 (A): Primary peritonitis (Spontaneous bacterial peritonitis, SBP):

·       Diagnostic paracentesis should be carried out without delay to confirm SBP in all cirrhotic patients with ascites on hospital admission, (Good practice statement).

·       Ascitic neutrophil count >250/mm³ remains the gold standard for SBP diagnosis, (Good practice statement).

(B): Secondary peritonitis:

·       We recommend for the diagnosis of IAIs should be based primarily on clinical assessment, basic laboratory tests, plain X-ray of the abdomen and ultrasound (Strong recommendation, moderate certainty evidence, ^{(3 & 4)}).

·       We advise against performing imaging in case of suspected peritonitis due to organ perforation in a critically ill patient, if it delays the surgical procedure, (Conditional recommendation, low certainty evidence, ⁽⁴⁾).

·       When peritonitis due to perforated gastroduodenal ulcer is suspected, the indication for surgery can be based on clinical history and the presence of pneumoperitoneum on plain abdominal X-ray, (Good practice statement).

·       In adult patients not undergoing immediate laparotomy, computed tomography (CT) scan is recommended to determine the presence of an intra-abdominal infection and its source, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾).

(C): Tertiary peritonitis:

·       Consider the diagnosis of ongoing IAI in the case of development or deterioration of organ dysfunction during the days following abdominal surgery for secondary peritonitis, (Conditional recommendation, low certainty evidence, ⁽³⁾).

(D): Peritoneal dialysis (PD) associated peritonitis:

·       If peritonitis is suspected, we recommend testing of the PD effluent for cell count, differential gram stain, and culture, (Strong recommendation, moderate certainty evidence, ⁽⁵⁾).

·       Peritonitis should be diagnosed when at least two of the following criteria are met:

1) Clinical features consistent with peritonitis; 2) Dialysis effluent WBC count > 100/µL (after ≥2h dwell) with >50% PMN; 3) Positive dialysis effluent culture, (Strong recommendation, low certainty evidence, ⁽⁵⁾.

Section 2:  Medical management:

·       Empirical broad spectrum antibiotic regimens are recommended, (Strong recommendation, moderate certainty evidence, ⁽⁶⁾). 

·       We recommend that, empirical antibiotic therapy protocols for community- acquired IAI to be established on the basis of regular analysis of national and regional microbiological data in order to quantify and monitor the course of microbial resistance in the community, (Strong recommendation, high certainty evidence, ⁽³⁾).

·       In severe IAI, empirical antibiotic therapy should be adapted to the suspected organisms, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       We recommend that, empirical broad spectrum antibiotic therapy to be initiated as soon as possible, using systemic intravenous (IV) route, after appropriate microbiological specimens have been obtained, (Strong recommendation, moderate certainty evidence, ^{(3 & 6)}). 

·       We recommend against empirical therapy against Candida in community-acquired IAI in the absence of signs of severity, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       We advise administration of antifungal therapy in severe peritonitis (community-acquired or postoperative), in the presence of at least 3 of the following criteria: hemodynamic failure, female gender, upper gastrointestinal surgery, antibiotic therapy for more than 48 hours, (Conditional recommendation, low certainty evidence, ⁽³⁾).

·       When adequate source control has been achieved, we recommend the antibiotic treatment duration to be shortened, (Strong recommendation, moderate certainty evidence, ⁽⁶⁾). 

Section 3: Surgical management:

(A): Primary peritonitis (Spontaneous bacterial peritonitis, SBP):

·       Where feasible, we advise performing percutaneous drainage, as it is preferable to surgical drainage, (Conditional recommendation, moderate certainty evidence, ⁽⁴⁾). 

(B): Secondary peritonitis:

·       We recommend that, a patient with suspected peritonitis due to organ perforation to be operated upon as rapidly as possible with proper resuscitation, especially in the presence of septic shock, (Strong recommendation, high certainty evidence, ⁽³⁾).

·       In the absence of hemodynamic instability (defined as the need for more than 0.1 mg/kg/min of epinephrine or norepinephrine), we advise that the decision to perform first-line image-guided percutaneous drainage for the management of intra-abdominal abscess in the absence of clinical or radiological signs of perforation to be based on a multidisciplinary discussion. This also allows for microbiological examination of peritoneal fluid samples, (Conditional recommendation, low certainty evidence, ⁽³⁾).

·       We advise obtaining peritoneal fluid samples in community-acquired IAI in order to identify the microorganism and determine their susceptibility to anti-infective agents, (Conditional recommendation, low certainty evidence, ⁽³⁾).

·       Routine source control procedures are recommended to remove infected fluid and tissue to prevent ongoing contamination in patients with IAI, except for those with clinical problems for which there is clear evidence that a non-interventional approach is associated with a good clinical outcome, (Strong recommendation, moderate certainty evidence, ^{(3, 4 & 6)}). 

·       We recommend that source control should be undertaken within 24 hours of the diagnosis of IAI, except for those infections for which clinical evidence indicates a non-interventional or delayed approach is appropriate. Source control should be undertaken in a more urgent manner in patients with sepsis or septic shock, (Strong recommendation, moderate certainty evidence, ^{(3, 4 & 6)}). 

·       We recommend that, surgical source control procedures should involve the resection or suture of a diseased or perforated viscus (e.g., diverticular perforation, gastroduodenal perforation), removal of the infected organ (e.g., appendix, gallbladder), debridement of necrotic tissue, resection of ischemic bowel, and repair or resection of traumatic perforations, (Strong recommendation, high certainty evidence, ⁽⁶⁾). 

·       We advise performing laparoscopy, as a less invasive approach for both the diagnosis and treatment for intra-abdominal infections, particularly when performed by experienced surgeons, (Conditional recommendation, high certainty evidence, ⁽⁶⁾). 

·       We recommend against laparoscopy for the treatment of peritonitis due to perforated peptic ulcer in a patient presenting more than one of the following risk factors: state of shock on admission, ASA score III- IV, and presence of symptoms for more than 24 hours, (Strong recommendation, moderate certainty evidence, ⁽³⁾), (table 3). 

·       We recommend against laparoscopy in the case of purulent or fecal peritonitis due to diverticulosis, (Strong recommendation, high certainty evidence, ⁽³⁾). 

·       For intra-abdominal abscesses, we recommend percutaneous drainage as the preferred first-line therapy over open surgical intervention, where feasible, due to its association with lower complication rates and shorter hospital stays, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾). 

·       Drainage should be checked by CT scan in the presence of signs of deterioration, (Strong recommendation, high certainty evidence, ⁽³⁾). 

·       We recommend against primary closure for controlling persistent infection, preventing abdominal compartment syndrome, or deferring definitive intervention and anastomosis. It is recommended as a potentially life-saving strategy in a carefully selected group of surgical patients with severe abdominal sepsis, particularly as part of a damage control strategy, (Strong recommendation, moderate certainty evidence, ⁽³⁾). 

 (C): Tertiary peritonitis:

·       We recommend performing re-laparotomy on the fourth or fifth day after the index operation in the absence of any signs of clinical or laboratory improvement, (Strong recommendation, moderate certainty evidence, ⁽³⁾). 

·       We recommend that, in the case of postoperative abscess, the benefit-risk balance of image-guided percutaneous drainage versus re-laparotomy should be assessed by a multidisciplinary team. (Strong recommendation, moderate certainty evidence, ⁽³⁾). 

·       We recommend performing double contrast-enhanced computed tomography of the abdomen and pelvis. In case of renal impairment, only oral contrast is done. (Strong recommendation, moderate certainty evidence, ⁽³⁾). 

(D): Peritoneal Dialysis (PD) associated peritonitis:

·       We recommend removal of the PD catheter in refractory peritonitis episodes, defined as failure of the PD effluent to clear after 5 days of appropriate antibiotics, (Strong recommendation, moderate certainty evidence, ⁽⁵⁾). 

·       We recommend immediate catheter removal when fungi are identified in PD effluent, (Strong recommendation, low certainty evidence, ⁽⁵⁾). 

·       We advise that treatment with an appropriate anti- fungal agent be continued for at least 2 weeks after catheter removal, (Conditional recommendation, low certainty evidence, ⁽⁵). 

·       We advise administration of anti-tuberculous therapy, instead of PD catheter removal, as the primary treatment of peritonitis caused by Mycobacterium tuberculosis, (Conditional recommendation, low certainty evidence, ⁽⁵⁾). 

Section 4: Post-operative care and complications management:

·       We recommend adjustment of the antibiotic therapy once results and sensitivities are known, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾). 

·       In patients suspected to be infected by resistant Enterobacteriaceae, ampicillin- and/or vancomycin-resistant enterococci or methicillin-resistant Staphylococcus aureus (MRSA), we recommend that, these strains should probably be taken into account in the empirical antibiotic therapy for healthcare-associated peritonitis, (Strong recommendation, moderate certainty evidence, ⁽³⁾). 

·       We recommend that empirical antifungal therapy to be initiated in healthcare-associated IAI, when yeast is detected on direct examination. Antifungal therapy (echinocandins in the case of serious infection or fluconazole-resistant strains) should probably be initiated in all cases of healthcare-associated IAI in which peritoneal fluid culture (apart from closed suction drains and drainage systems, etc.) is positive for yeasts, (Strong recommendation, moderate certainty evidence, ⁽³⁾). 

Section 5: Peritonitis prevention:

(A) Spontaneous Bacterial Peritonitis (SBP) Prophylaxis:

·       We advise primary prophylaxis to patients considered at high risk, as defined by an ascitic protein count <1.5 g/dL. However, it is important that the potential risks and benefits and existing uncertainties are communicated to patients, (Conditional recommendation, low certainty evidence, ⁽⁴⁾).

·       For patients who have recovered from an episode of SBP, we advise for treatment with norfloxacin, ciprofloxacin, or co-trimoxazole to prevent further episodes of SBP, (Conditional recommendation, low certainty evidence, ⁽⁴⁾).

·       For patients presenting with gastrointestinal bleeding and underlying ascites due to cirrhosis, we recommend receiving prophylactic antibiotic treatment (cefotaxime has been widely studied but the antibiotic should be chosen based on local data) to prevent the development of SBP, (Strong recommendation, high certainty evidence, ⁽⁴⁾).

 (B) Peritoneal Dialysis (PD)-Associated Peritonitis Prevention:

·       We recommend that systemic prophylactic antibiotics be administered immediately prior to catheter placement, (Strong recommendation, high certainty evidence, ⁽⁵⁾).

·       We advise prophylactic antibiotics after wet contamination of the PD system to prevent peritonitis, (Conditional recommendation, very low certainty evidence, ⁽⁵⁾).

·       We advise antibiotic prophylaxis prior to colonoscopy and invasive gynecological procedure, (Conditional recommendation, low certainty evidence, ⁽⁵⁾).

·       We advise performing drainage of PD fluid to keep the abdomen empty before endoscopic gastrointestinal and invasive or instrumental gynecological procedures, (Conditional recommendation, very low certainty evidence, ⁽⁵⁾).

·       To prevent fungal peritonitis, we recommend that anti-fungal prophylaxis be co-prescribed whenever PD patients receive an antibiotic course, regardless of the indication, (Strong recommendation, moderate certainty evidence, ⁽⁵⁾).