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• usually mixture of aerobes, facultatives and anaerobes
• aerobic/facultative organisms, esp. E. coli responsible for initial peritonitis and septicaemia while anaerobes major causes of abscess formation in animal models
• although enterococci commonly isolated in intra-abdominal infections regimes which do not cover or have poor cover for enterococci appear to be successful with no treatment failures due to infection by enterococci in any of 6 published trials. ?unnecessary to cover enterococci in first-line regimes

• clindamycin or metronidazole plus aminoglycoside
• monotherapy with cefoxitin or imipenem probably as good and results with imipenem may be better than combination therapy. Piperacillin/tazobactam may be better than imipenem
• clindamycin plus aztreonam or ceftazidime as effective as clindamycin plus aminoglycoside and has advantage of avoiding aminoglycoside induced nephrotoxicity
• aminoglycoside should be used in following situations

• prior antibiotics (previous 30 days)
• resistant gram negatives
• reoperation or recurrence of infections
• prolonged pre-op hospitalization

• duration of antibiotic therapy unresolved issue

Surgical peritonitis is one of a group of infections for which it is vital to provide adequate antibiotic cover from the start. Outcome is dependent on choosing the right antibiotics. If initial antibiotic cover is inadequate, changing to the appropriate antibiotics based on microbiological results does not appear to improve prognosis. It is thought that this is because micro-abscesses have formed by this stage.

© Charles Gomersall November 1999

©Charles Gomersall, October, 2009 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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