Treatment of Peritonitis

Initial Management

The American College of Surgeons recommends immediate fluid resuscitation to enhance visceral perfusion and address volume depletion in patients with peritonitis 1, 3
Broad-spectrum antibiotics should be administered as soon as possible, ideally within 1 hour for patients with septic shock, as recommended by the World Journal of Emergency Surgery 1, 4
Empiric antibiotic therapy should target a mixture of Gram-negative, Gram-positive, and anaerobic bacteria, based on the polymicrobial nature of peritonitis, according to the World Journal of Emergency Surgery 5, 4

Emergency surgical intervention should be performed as soon as possible in patients with diffuse peritonitis, even if ongoing measures to restore physiologic stability need to be continued during the procedure, as recommended by the Praxis Medical Insights and World Journal of Emergency Surgery 1, 4
The primary goals of surgery are to drain infected foci, control ongoing peritoneal contamination, and restore anatomic and physiological function, according to the Praxis Medical Insights and World Journal of Emergency Surgery 1, 2
For perforated diverticulitis with diffuse peritonitis, Hartmann's procedure is recommended in critically ill patients, as suggested by the Praxis Medical Insights and World Journal of Emergency Surgery 1, 2

For non-critically ill, immunocompetent patients with adequate source control, piperacillin/tazobactam is recommended by the World Journal of Emergency Surgery 2, 4
For patients with high risk of ESBL-producing Enterobacterales, ertapenem or eravacycline is recommended by the World Journal of Emergency Surgery 2
For septic shock, meropenem, doripenem, imipenem/cilastatin, or eravacycline is recommended by the World Journal of Emergency Surgery 2

For patients with adequate source control, a short course (3-5 days) of antibiotic therapy is recommended by the World Journal of Emergency Surgery 4, 5
For immunocompromised or critically ill patients with adequate source control, antibiotic therapy up to 7 days is recommended by the World Journal of Emergency Surgery 2, 4

If secondary bacterial peritonitis is suspected, imaging tests such as abdominal computed tomography should be performed, as recommended by the Clinical and Molecular Hepatology 7
Antifungal therapy is recommended for hospital-acquired infections and in patients who are critically ill or severely immunocompromised, according to the World Journal of Emergency Surgery 5

On-demand re-laparotomy is recommended for patients with severe peritonitis, as it streamlines healthcare resources and reduces overall medical costs, according to the World Journal of Emergency Surgery 4, 6
Open abdomen may be a viable option for treating physiologically deranged patients with ongoing sepsis, facilitating subsequent exploration and control of abdominal contents, and preventing abdominal compartment syndrome, as suggested by the World Journal of Emergency Surgery 4, 6