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Post Operative Peritonitis
- 1. Post Operative Peritonitis IC ofClinical Pathology: Choi Kin Heng Tutor: Dr. Jose Mario Martins Drogas 1
- 2. Peritonitis --An infection ofthe abdominal cavity with reaction of the “organ” peritoneum.
- 3. Type Definition Microbiology Primary (Spontaneous) Aperitoneal infection developing in the absence of a break in the integrity of the GI tract, as a result of hematogenous or lymphatic seeding, or bacterial translocation Monomicrobial infection due to G- Enterobacteriaceae or streptococci Secondary A peritoneal infection developing in conjunction with an inflammatory process of the GI tract or its extensions, usually associated with microscopic or macroscopic perforation Polymicrobial infection due to aerobic G- bacilli, G+ cocci, and enteric anaerobes Tertiary A persistent or recurrent peritoneal infection developing after initial treatment of secondary peritonitis Nosocomial organisms, including resistant G- bacilli, enterococci, staphylococci, and yeast
- 4. Pathogenetic Principles Intact gutwall Loss of gut wall integrity Intestinal hypomotility, Local immunodeficiency Mucosal edema Bacterial overgrowth Transmural migration Bacterial translocation LymphBlood Intraperitoneal seeding of pathogens Spontaneous bacterial peritonitis (Localized) Secondary peritonitis Adjuvants: Blood (iron), necrotic tissue, barium, bowel contents More and more virulent bacteria Insufficient immune response (eg. Low complement) Ulcer perforation, trauma, severe colitis, diverticulitis, surgery...
- 5. Pathogenetic Principles Ulcer perforation,trauma, visceral wall infection surgery Efficient host response + Abx Inefficient host response, adjuvants Secondary peritonitis Containment Abscess Cure Tertiary peritonitis Efficient surgery + Abx Drainage + Abx Efficient surgery + Abx Rupture spread Inefficient surgery + Abx
- 6. Post-operative Peritonitis •Subsumed asa form of Secondary peritonitis •Occurs after an anastomotic failure, undetected injury of the small or large bowel etc... •Always a hospital-acquired form of peritonitis •High risk for multidrug-resistant microorganisms 6
- 7. •Morbidity and mortality↑ ↑ •Multidisciplinary approach (Surgeon intensivist, interventional radiology, infectious diseases...) •Early diagnosis and correction underlying microvascular disfunction ↑ ↑ survival 7 Post-operative Peritonitis
- 8. Post-operative Peritonitis •Severity ofillness among patients with postoperative peritonitis can differ dramatically 8
- 9. Diagnosis of postoperativeperitonitis •Symptoms and signs Abdominal pain, new / sudden onset clinical impairment, SIRS •PE Abd tenderness, distention, rigidity, rebound... •Clinical findings may be altered or absent In critically ill patient or among patients with immune suppression or under chemotherapy •Consider septic shock if Hypotension, oliguria, organ dysfunction, and altered mental status 9
- 10. • Laboratory CRP, WBC,PCT • Changes of the drainage content, amount, quality... normal amount does not exclude PP check drainage amylase, lipase, bile .... • Abdominal ultrasound • Percutaneous diagnostic puncture • CT 10 Diagnosis of postoperative peritonitis
- 13. Treatment of postoperative peritonitis -Focus Elimination •Immediate focus elimination is the goal •Resection of the infectious focus or the organ responsible for PP with restoration of intestinal integrity is the safest way, but cannot always be achieved •percutaneous drainage can also be sufficient for anastomosis leaks
- 14. Intensive Care Management •Goal:support organ dysfunction and to avoid multiple organ failure •Balance oxygen delivery with oxygen demand •Cornerstone of the initial intensive care management: - Sufficient fluid resuscitation - Appropriate inotropic agents •Guide fluid therapy: CVP, MAP 14
- 15. Antibiotic Treatment •Early administrationof broad-spectrum antibiotics Basis •Must anticipate the most common microorganisms according to the operative field •Same microorganisms that can be found in patients with community- acquired peritonitis, but there is a higher probability of opportunistic microorganisms •Eg: ESBL, VRE, MRSA, Pseudomonas A., Candida spp. Etc… 15
- 16. Microorganisms according tothe operative field
- 17. Antibiotic treatment optionsfor suspected resistant microorganisms
- 18. In Post-operative peritonitis •Enterococci↑↑ •Enterobacter species ↑↑ •E. Coli ↓↓
- 20. Treatment Strategy 1. HitHard and Early •The initial treatment should be: - Broad enough to cover all kinds of possible resistant microorganisms - Should be initiated as soon as possible •Delay of an appropriate antibiotic therapy increases the risk for mortality 20
- 21. Treatment Strategy 2. Listento Your Hospital •Antibiotics should be: - Selected according to the local surveillance data •Regular evaluation of the microorganisms encountered in patients with postoperative peritonitis should guide the antibiotic therapy 21
- 23. Treatment Strategy 3. Lockat your patient •Risk for infections with multidrug-resistant microorganisms •Risk is even higher if: - patient already had a prior broad-spectrum abx therapy - patient suffered from severe comorbidities - patient already had a long post operative in hospital stay 23
- 24. Treatment Strategy 4. Getto the Point •Initial dose high enough to reach a sufficient concentration at the focus •Antibiotics should be selected according to pharmacokinetics and pharmacodynamics characteristics enable a good tissue penetration to reach a high concentration at the focus peritoneum 24
- 25. Treatment Strategy 5. Focus,Focus, Focus •Avoid a long-term ineffective broad- spectrum antibiotic exposure •After effective focus elimination, a critical evaluation of the results of the microbiology should be performed •In stable patients, de-escalation of the antibiotic therapy is essential to prevent the development of even more resistant microorganism 25
- 26. Case • 65 year-old,Male, Past history: Denied past medical history • Chief complaints: Abdominal pain for 3 days with nausea. • PE: BP: 88/65mmHg, T: 38C, P: 109/min • ABD: Mild tightness, and defuse tenderness, and rebound tenderness, hypoactive bowel sound • Lab test: Cr 311umolL (BL 50), Hb 11.8g/dL, CRP 44mg/dL, PCT >100 ng/mL
- 27. • Abd +Pelvic CT on 2021/09/30 Hollow organ perforation
- 28. • Pre-pyloric perforation simplerepair was done on 01/10/2021, No drainage • Patient presented on and off low grade fever with Ceftriaxone + Metronidazole after operation • Control Abd+Pelvic CT on 2021/10/18 >
- 29. • Paracentesis atRLQ was done on 2021/10/22, turbid – yellowish drainage • Culture: Candida albicans, Anti-fungal was given • Controlled CT on 2021/11/12 and IR drainage was done
- 30. Which type ofperitonitis did this patient has
- 31. Pathogenetic Principles Ulcer perforation,trauma, visceral wall infection surgery Efficient host response + Abx Inefficient host response, adjuvants Secondary peritonitis Containment Abscess Cure Tertiary peritonitis Efficient surgery + Abx Drainage + Abx Efficient surgery + Abx Rupture spread Inefficient surgery + Abx
- 32. Conclusion • Postoperative peritonitismostly occurs secondary to an anastomotic failure after different abdominal operations and is associated with an inverse oncological outcome and increased mortality. • The most important issues to prevent septic shock are early diagnosis and immediate and effective treatment. • Focus elimination is the basis of an effective treatment. • Successful treatment of postoperative peritonitis requires modern intensive care management and antibiotic therapy with special focus on resistant microorganisms
- 33. References • The Microbiologyof Postoperative Peritonitis. A. Roehrborn, 1L. Thomas, 2O. Potreck. Ebener. Ohmann,P. E. Goretzki and H. D. Ro¨her • Dahms RA, Johnson EM, Statz CL, et al. Third generation cephalosporins and vancomycin as risk factors for postoperative vancomycin resistant enterococcus infection. Arch Surg 1998;133:1343– 6. • Magnussen CR, Cave J. Nosocomial enterococcal infections:association with the use of third generation cephalosporin antibiotics. Am J Infect Control 1998;16:241–5. • Sawyer RG, Rosenlof LK, Adams RB, et al. Peritonitis into the 1990s: • changing pathogens and changing strategies in the critically ill. Am Surg 1992;58:82–7. • Diffuse postoperative peritonitis – Value of diagnosis parameters and impact of early indication of relaparotomy, F. G. Bader, M. Schröder, P. Kujath, E. Muhl, H.-P. Bruch, C. Eckmann • Abdominal Sepsis, Massimo Sartelli, Matteo Bassetti, Ignacio Martin-Loeches
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