Antibiotic Treatment for Peritonitis

Community-Acquired Peritonitis

The World Society of Emergency Surgery recommends amoxicillin-clavulanate or ciprofloxacin plus metronidazole for extra-biliary or biliary acute infections in patients who are not critically ill and have no risk factors for extended-spectrum β-lactamases 2
For community-acquired peritonitis of mild-to-moderate severity, amoxicillin-clavulanate, cefazolin or cefuroxime plus metronidazole, or ertapenem are recommended 1
For high-severity community-acquired peritonitis, piperacillin-tazobactam, imipenem-cilastatin, meropenem, or a third/fourth-generation cephalosporin plus metronidazole are recommended 1

The World Society of Emergency Surgery recommends piperacillin-tazobactam or tigecycline for hospital-acquired peritonitis without critical illness but with risk of multidrug-resistant organisms 2
For critically ill patients, piperacillin-tazobactam, tigecycline, or a carbapenem are primary options 2

Empirical enterococcal coverage is not recommended for community-acquired infections, but should be considered for postoperative/nosocomial peritonitis 3
Antifungal therapy should be considered in critically ill patients with hospital-acquired peritonitis 2
Avoid fluoroquinolone monotherapy without metronidazole due to increasing B. fragilis resistance 1
Review local susceptibility patterns before using ampicillin-sulbactam due to increasing E. coli resistance 1
Carbapenem overuse should be avoided to reduce selective pressure for carbapenem-resistant Enterobacteriaceae 4