Optimal duration of therapy is not known

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optimal duration of therapy is not known; traditionally, a course of 10 days is recommended, although studies have suggested that 5 days of therapy (with documentation of a decrease of peritoneal fluid WBC count to <250 cells/μ L) may be sufficient in most cases. The patient with SBP is also likely to require attention to changes in hemodynamic function related to inflammatory pathways, as well as resultant renal function impairment, although a discussion of this is beyond the scope of this chapter. There is a high risk of relapse after SBP (40-70% in 12 months); a variety of prophylactic antibiotic regimens are available. A preliminary study of norfloxacin for primary prophylaxis of SBP was positive. Secondary and tertiary peritonitis In secondary and tertiary peritonitis, systemic antibiotic therapy is the second mainstay of treatment. Several studies suggest that antibiotic therapy is not as effective in the infection's later stages and that early (preoperative) systemic antibiotic therapy can significantly reduce the concentration and growth rates of viable bacteria in the peritoneal fluid. Antibiotic therapy begins with empiric coverage (effective against common gram negative and anaerobic pathogens) and should be initiated as soon as possible, with a transition made to narrower spectrum agents as culture results become available. Perforations of upper GI tract organs are associated with gram-positive bacteria, whereas the distal small bowel and colon perforations involve polymicrobial aerobic and anaerobic species. Culture results may be especially important in tertiary peritonitis, which is more likely to involve gram-positive bacteria (enterococci); antibiotic-resistant, gram- negative bacteria; and yeast. In community-acquired infections, a second- or third- generation cephalosporin or a quinolone with or without metronidazole provides adequate coverage, as do broad-spectrum penicillins with anaerobic activity (ie, ampicillin/sulbactam) and newer quinolones (ie, trovafloxacin, clinafloxacin). Most studies suggest that single-drug therapy is as effective as dual or triple combination therapy in mild to moderate abdominal infections. For peritoneal dialysis – associated infections, Cochrane reviews of all published randomized, controlled trials have not found significant differences between antimicrobial agents or combinations, with similar response and relapse rates for glycopeptide regimens and first-generation cephalosporins. Intraperitoneal antibiotics had a lower failure rate than intravenous regimens. Risk for early peritonitis is reduced with perioperative intravenous antibiotics; other prophylactic approaches are not yet proven. 21
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In severe and hospital-acquired intra-abdominal infections, imipenem, piperacillin/tazobactam, and a combination of aminoglycosides and metronidazole are often effective. A study of nearly 400 patients documented that ertapenem, a novel carbapenem with a half-life that allows once-a-day dosing, was effective (86.7% success rate) compared to piperacillin/tazobactam (81.2% success rate) in the
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  • Winter '18
  • Jane doe
  • Sula, Peritoneum, peritoneal dialysis, Peritonitis

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