bacterial pretonitis

Question 1

anatomy of the abdomen: * Peritoneum: continuous — membrane lining the— and covering the —
1. Parietal peritoneum (attached to — )
2. Visceral peritoneum (wrapped around —)
Peritoneal cavity: potential space between — and — peritoneum.

Answer 1

serous
abdominal cavity
abdominal viscera
abdominal wall
visceral organs
pariteal and vsiceral

Question 2

ANATOMY OF THE ABDOMEN:
* Intraperitoneal organs are enveloped by —
peritoneum, which covers the organ both — and —
– As: – , — and — are all intraperitoneal
* Retroperitoneal organs are only covered in —
peritoneum, which only covers their – surface
*As: — , — , — , ascending and descending — , —

Answer 2

visceral peritoneum
anteriorly and posteriorly
stomach liver and spleen
parietal
anterior
oesophagus , kidney , pancreas , colon , rectum

Question 3

PERITONITIS
Inflammation of the —
Resulting in an —
which rapidly becomes —
Localised or generalised
Localised: e.g. —- appendix
Generalised: e.g. — colon
Arises from contamination of the — , which is normally –
* microorganisms ( — , —)
* Irritating — (bile, urine, gastric content, blood)
* Both

Answer 3

peritoneum
exudate
purulent
inflamed
perforated
peritoneal cavity
sterile
bacteria , fungi
chemicals

Question 4

peritonitis classifications:
1- — / —- Bacterial Peritonitis
2- — Peritonitis
3-Peritoneal —-associated peritonitis

Answer 4

primary/spontanous
2ndary
dialysis

Question 5

PRIMARY/SPONTANEOUS BACTERIAL
PERITONITIS (SBP):
Inflammation of the
peritoneum, without an
obvious —
May be seen in patients with pre-existing — (e.g. in
— disease)
Does not involve — of abdominal wall and intra-
abdominal organs
No — defect in the gastro-intestinal tract
Bacterial — or — spread

Answer 5

obvious source
ascites
chronic liver
disruption
macroscopic
translocation or haematgousn

Question 6

SECONDARY PERITONITIS
Inflammation of the peritoneum due to a process causing — of mucosal — or —
– Perforation (appendix, colon, ulcer)
– Intra-abdominal — /—
– Pancreatitis (bile and chemicals)
– Trauma/penetrating injury
– Post procedure/Iatrogenic (e.g. anastomotic leak, after
colonoscopy)

Answer 6

interruption
integrity or perforation
lesions/spillage
info:
If you don’t send a specimen of peritoneal fluid to microbiology – you won’t
know what microorganism(s) are causing the infection or what antimicrobials
they are resistant or susceptible to, i.e. what antibiotics to use!

Question 7

PERITONEAL DIALYSIS (PD)- ASSOCIATED PERITONITIS:
* PD ( — ) catheter
provides a portal of entry
for — into the
normally — peritoneum
*‘—–contamination’ or—-site infection
* less commonly, — source

Answer 7

tenckoff
organisms
sterile
touch
exit site
intra abdominal source

Question 8

PERITONITIS: CLINICAL FEATURES
On examination: usually presents as an —
– acute abdominal pain
– — abdomen, —
– ( — ) tenderness to —
– distension
– percussion tenderness
– N+V, anorexia
Patient may have features of— – fever,
tachycardia, hypotension, oliguria, — skin

Answer 8

acute abdomen
rigid
guarding
rebound
palpation
sepsis
mottled skin

Question 9

PERITONITIS: CLINICAL FEATURES
* If PD peritonitis, symptoms may also include:
– — dialysis fluid
– White —, strands or clumps ( — ) in the dialysis fluid

Answer 9

cloudy
white flecks
fibrin

Question 10

peritonitis aetiology:
PRIMARY/SBP
* Remember: No obvious –
* Infection of — fluid
* Risk factors include — of the liver
* Majority are —

• Usually — bacteria
  – Enterobacterales: E. coli, K. pneumoniae
  – Pseudomonas aeruginosa
  – S. pneumoniae, GAS, enterococci, Staphylococcus
  aureus
  – Anaerobes –

Answer 10

obvious source
ascitic
cirrhosis
mono microbial
aerobic bacterial
rarely

Question 11

PERITONITIS: AETIOLOGY
SECONDARY PERITONITIS
* Occurs secondary to — of — or — tract microorganisms into the sterile —
* Majority of infections are —-
* Causative microorganisms include — &— bacteria, and — species that reflect the usualflora of the area of diseased GIT
* Enterobacterales
* Enterococci, streptococci
* Bacteroides spp., Prevotella spp., other anaerobes
* Candida spp.

Answer 11

spillage
GIT or genitourinary
peritoneal cavity
poly microbial
aerobic and anaerobic
candida

Question 12

PERITONITIS: AETIOLOGY
PERITONEAL DIALYSIS (PD)-ASSOCIATED
PERITONITIS
* Skin flora:
– — , —
* Less commonly:
– GI flora:
* E. coli, Pseudomonas aeruginosa
* Transmural: GI bacteria migrate through the bowel
wall
– Anaerobes rarely

Answer 12

S. aureus, CoNS

Question 13

PERITONITIS: DIAGNOSIS
* Clinical signs & symptoms
* Laboratory
– Routine bloods (FBC, U+Es, LFTs, coagulation profile,
CRP)
– — (to outrule pancreatitis)
– —
– Blood for group and save/crossmatch (in case requires
surgery and/or blood transfusion)
– Venous/arterial blood gas if shock/ischaemia
– Procalcitonin (PCT) if —
↑CRP, ↑WCC, indicates inflammation/infection

Answer 13

amylase
lactase
pancreatitis

Question 14

PERITONITIS: DIAGNOSIS
Microbiology
* Blood cultures
* Urine C&S
* Peritoneal fluid specimen
(depends on likely aetiology):
– Intra-operative specimen of pus or fluid- ( — peritonitis)
* Gram stain and culture
– Ascitic tap ( —
peritonitis/SBP)
* Cell count, Gram stain and culture
– Peritoneal dialysis (PD) fluid
* Cell count, Gram stain and culture\
Radiology:
* Abdominal X-ray (erect)
– May miss small amounts of free air
* CT abdomen & pelvis
– contrast
* Ultrasound scan
– No contrast used
– Identifies free fluid
– Can be done at bedside

Answer 14

2ndary
primary
( info: ERECT CXR - FREE AIR UNDER THE
DIAPHRAGM)

Question 15

MANAGEMENT OF PERITONITIS
Initially
* — the bowel - NPO
* Large-bore IV cannula
* Analgesia
* IV fluids
* Further management depends on — presentation – may need
surgical exploration
* If sepsis/septic shock, — treatment in critical care setting may be required (oxygen, ventilation, inotropes, dialysis)

Answer 15

rest
clinical
supportive

Question 16

MANAGEMENT OF
SECONDARY PERITONITIS
1) Empiric antimicrobials (Local Beaumont guidelines – check the app)
– Choice based upon likely — and — scenario (community versus hospital-acquired infection)
– Empiric = peritoneal — culture & — result not
yet available:

• Community-acquired: 2nd generation — (cefuroxime)
  + — (gentamicin) + —
  OR
• Hospital-acquired —inhibitor combination
  (piperacillin-tazobactam) + — (gentamicin)

– Adding an empiric — agent (caspofungin or fluconazole) may
be recommended in certain scenarios – check local guidelines and
discuss with clinical microbiologist

Answer 16

microorganism anf clinical
fluid and susceptility
cephalosporin m aminoglycoside , metronidazole
β-lactam/β-lactamase , aminoglycoside
anti fungal

Question 17

MANAGEMENT OF
SECONDARY PERITONITIS
Rationale: Spectra of activity of antibiotic (revision)
– Cefuroxime: aerobic Gram positive cocci and gram negative
bacilli (not Pseudomonas). No anaerobic cover - metronidazole
added to provide the anaerobic cover
– Co-amoxiclav: aerobic GPC and GNB (not Pseudomonas) and
anaerobic cover, no need to add metronidazole
– Pip/tazo aerobic GPC and GNB (including Pseudomonas) and
anaerobic cover - no need to add metronidazole
– Gentamicin is second agent added to provide Gram negative
cover, just in case of resistance to pip/tazo or cefuroxime (given
for 48 hours while waiting for peritoneal fluid C&S). Gentamicin
does not provide anaerobic cover

Question 18

START SMART – THEN FOCUS
Aim of empiric treatment: cover the likely —
for the — scenario
* Peritonitis: cover bowel microorganisms: Gram —
and —
* Check lab results for any prior — microbiology results
* Once results available (blood cultures, peritoneal fluid) –Target — therapy:
– Resistant microorganisms: —
– Susceptible microorganisms :—
REMEMBER: If you don’t send a specimen of peritoneal fluid to
microbiology, you won’t learn the causative microorganisms and
susceptibility results and you won’t be able to target empirical
antibiotic therapy

Answer 18

microorganism
clinical
gram -ves and anaerobes
positive
antimicrobial
escalate
de escalate

Question 19

MANAGEMENT OF
SECONDARY PERITONITIS
2) — control : remove source of contamination and — any anatomical or functional defect
– Appendicectomy, bowel resection, repair of perforation
– — of abscess (operating theatre/interventional
radiology)

If laparotomy being performed, peritonitis may be evident as – or — material in peritoneal cavity
– Needs — or ‘—’
– Specimen of fluid/faecal material should be sent promptly
to Microbiology for culture and susceptibility testing

Answer 19

source
repair
drainage
purulent or faecal
washout or lavage

Question 20

MANAGEMENT OF PRIMARY PERITONITIS
(SBP) OR PD PERITONITIS
Typically monomicrobial infection, but you need to also
exclude occult perforation (polymicrobial infection)
* Specimen of peritoneal fluid:
– SBP = ascitic tap or diagnostic paracentesis of ascitic fluid
for cell count, Gram stain, culture & susceptibility
– PD-peritonitis = PD fluid for cell count, Gram stain, culture
and susceptibility and PD catheter exit site swab
* Empiric antimicrobials:
– IV route for primary peritonitis (SBP)
– PD peritonitis may be treated via intraperitoneal (IP) route – PD
catheter allows direct administration into peritoneal cavity
* PD catheter may need removal or exchange

Question 21

COMPLICATIONS OF BACTERIAL
PERITONITIS
* Bloodstream infection (BSI)
* Sepsis/septic shock
* Localised abscess/collection
* Adhesions
– Fibrous scar tissue as a result of
peritoneal inflammation
– Can result in abnormal attachments
between visceral peritoneum of
adjacent organs, or between visceral
and parietal peritoneum.
– May cause pain, volvulus, intestinal
obstruction

Question 22

SUMMARY
* Peritonitis to be suspected based on signs & symptoms of an acute
abdomen
* Peritonitis may be classified into primary (SBP), secondary, and peritoneal
dialysis (PD)-associated peritonitis
* Causative microorganisms vary depending on underlying aetiology –
Mainly bacteria, but fungi (Candida species) in some cases
* Diagnosis of peritonitis requires a clinical examination, laboratory,
microbiological and radiological investigations
* Send specimen of peritoneal fluid to microbiology!
* Peritonitis is usually managed with a combination of empiric antimicrobial
therapy PLUS source control (drainage/surgery, repair of perforation)
* Choice of empiric antimicrobial should cover likely microorganisms.
Include anaerobic cover for secondary peritonitis.