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Therapeutic management of peritonitis: a comprehensive guide for intensivists

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Abstract

Purpose

The management of peritonitis in critically ill patients is becoming increasingly complex due to their changing characteristics and the growing prevalence of multidrug-resistant (MDR) bacteria.

Methods

A multidisciplinary panel summarizes the latest advances in the therapeutic management of these critically ill patients.

Results

Appendicitis, cholecystitis and bowel perforation represent the majority of all community-acquired infections, while most cases of healthcare-associated infections occur following suture leaks and/or bowel perforation. The micro-organisms involved include a spectrum of Gram-positive and Gram-negative bacteria, as well as anaerobes and fungi. Healthcare-associated infections are associated with an increased likelihood of MDR pathogens. The key elements for success are early and optimal source control and adequate surgery and appropriate antibiotic therapy. Drainage, debridement, abdominal cleansing, irrigation, and control of the source of contamination are the major steps to ensure source control. In life-threatening situations, a "damage control" approach is the safest way to gain time and achieve stability. The initial empirical antiinfective therapy should be prescribed rapidly and must target all of the micro-organisms likely to be involved, including MDR bacteria and fungi, on the basis of the suspected risk factors. Dosage adjustment needs to be based on pharmacokinetic parameters. Supportive care includes pain management, optimization of ventilation, haemodynamic and fluid monitoring, improvement of renal function, nutrition and anticoagulation.

Conclusions

The majority of patients with peritonitis develop complications, including worsening of pre-existing organ dysfunction, surgical complications and healthcare-associated infections. The probability of postoperative complications must be taken into account in the decision-making process prior to surgery.

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Author information

Authors and Affiliations

  1. APHP, CHU Bichat-Claude Bernard, Département d’Anesthésie Réanimation, Université Denis Diderot, PRESS Sorbonne Cité, Paris, France

    P. Montravers

  2. Department of Internal Medicine, Ghent University, Ghent, Belgium

    S. Blot

  3. Department of Critical Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece

    G. Dimopoulos

  4. Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Peine, Germany

    C. Eckmann

  5. Department of Intensive Care Medicine and Burn Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

    P. Eggimann

  6. Department of Endocrine and Head and Neck Surgery, Corporació Sanitaria del Parc Tauli, University Hospital, Sabadell, Barcelona, Spain

    X. Guirao

  7. Emergency and Intensive Care Department, Centro Hospitalar S. João EPE, Porto, Portugal

    J. A. Paiva

  8. Department of Surgery, Catholic University of Sacred Heart, Policlinico A Gemelli, Rome, Italy

    G. Sganga

  9. Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium

    J. De Waele

  10. Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia

    S. Blot

  11. Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal

    J. A. Paiva

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  4. C. Eckmann
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Correspondence to P. Montravers.

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Take-home message: Critically ill patients with peritonitis require an early combined operative and medical approach. The key elements for success are appropriate anti-infective therapy (in terms of the most appropriate drug, at an adequate dosage with satisfactory tissue penetration to target the microorganisms concerned) and early and optimal source control and adequate surgery, comprising a “damage control” approach in life-threatening situations.

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Montravers, P., Blot, S., Dimopoulos, G. et al. Therapeutic management of peritonitis: a comprehensive guide for intensivists. Intensive Care Med 42, 1234–1247 (2016). https://doi.org/10.1007/s00134-016-4307-6

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  • DOI: https://doi.org/10.1007/s00134-016-4307-6

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