Skip to main content
Log in

Abstract

Intraabdominal infections are commonly encountered in clinical practice and represent a major cause of morbidity and mortality. The most common etiology is contamination of the peritoneal space by endogenous microflora secondary to loss of integrity of the gastrointestinal tract which results in secondary peritonitis. Primary peritonitis or spontaneous bacterial peritonitis is less common and usually occurs in the presence of ascites without an evident source of infection. Peritonitis associated with chronic ambulatory peritoneal dialysis is not discussed in this review. This review summarizes the significant progress which has been made with regard to primary and secondary peritonitis in the last two decades. The review emphasizes the issues of etiology, pathogenesis, microbiology, diagnosis, medical treatment and prevention.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. McClean KL, Sheehan GJ, Harding GKM: Intraabdominal infection: a review. Clinical Infectious Diseases (1994) 19:100–116

    Google Scholar 

  2. Speck WT, Dresdale SS, McMillan RW: Primary peritonitis and the nephrotic syndrome. American Journal of Surgery (1974) 127:267–269

    Google Scholar 

  3. Thomas FB, Fromkes JJ: Spontaneous bacterial peritonitis associated with acute viral hepatitis. Journal of Clinical Gastroenterology (1982) 4:259–262

    Google Scholar 

  4. Isner J, Macdonald JS, Schein PS: SpontaneousStreptococcus pneumoniae peritonitis in a patient with metastatic gastric carcinoma. Cancer (1977) 39:2306–2309

    Google Scholar 

  5. Shesol BF, Rosato EF, Rosato FE: Concomitant acute systemic lupus erythematosus and primary pneumococcal peritonitis. American Journal of Gastroenterology (1975) 63:324–326

    Google Scholar 

  6. Schweinburg FB, Seligman AM, Fine J: Transmural migration of intestinal bacteria: a study based on the use of radioactiveEscherichia coli. New England Journal of Medicine (1950) 242:747–751

    Google Scholar 

  7. Lahnborg G, Friman L, Berghem L: Reticuloendothelial function in patients with alcoholic liver cirrhosis. Scandinavian Journal of Gastroenterology (1981) 16:481–489

    Google Scholar 

  8. Rimola A, Soto R, Bory F, Arroyo V, Piera C, Rodes J: Reticuloendothelial system phagocytic activity in cirrhosis and its relation to bacterial infections and prognosis. Hepatology (1984) 4:53–58

    Google Scholar 

  9. Kourilsky O, Leroy C, Peltier AP: Complement and liver cell function in 53 patients with liver disease. American Journal of Medicine (1973) 55:783–790

    Google Scholar 

  10. Simberkoff MS, Moldover NH, Weiss G: Bactericidal and opsonic activity of cirrhotic ascites and nonascitic peritoneal fluid. Journal of Laboratory and Clinical Medicine (1978) 91:831–839

    Google Scholar 

  11. Yousif-Kadaru AGM, Rajkovic IA, Wyke RJ, Williams R: Defects in serum attractant activity in different types of chronic liver disease. Gut (1984) 25:79–84

    Google Scholar 

  12. Rajkovic IA, Williams R: Abnormalities of neutrophil phagocytosis, intracellular killing and metabolic activity in alcoholic cirrhosis and hepatitis. Hepatology (1986) 6:252–262

    Google Scholar 

  13. Conn HO, Fessel JM: Spontaneous bacterial peritonitis in cirrhosis: variations on a theme. Medicine (1971) 50:161–197

    Google Scholar 

  14. Pinzello G, Simonetti RG, Craxi A, Di Piazza S, Spano C, Pagliaro L: Spontaneous bacterial peritonitis: a prospective investigation in predominantly nonalcoholic cirrhotic patients. Hepatology (1983) 3:545–549

    Google Scholar 

  15. Boixeda D, De Luis DA, Aller R, De Argilla CM: Spontaneous bacterial peritonitis: clinical and microbiological study of 233 episodes. Journal of Clinical Gastroenterology (1996) 23:275–279

    Google Scholar 

  16. Wilcox CM, Dismukes WE: Spontaneous bacterial peritonitis: a review of pathogenesis, diagnosis, and treatment. Medicine (1987) 66:447–456

    Google Scholar 

  17. Sheckman P, Onderdonk AB, Bartlett JG: Anaerobes in spontaneous bacterial peritonitis. The Lancet (1977) 2:1223

    Google Scholar 

  18. Garcia-Tsao G, Conn HO, Lerner E: The diagnosis of bacterial peritonitis: comparison of pH, lactate concentration and leukocyte count. Hepatology (1985) 5:91–96

    Google Scholar 

  19. Stassen WN, McCullough AJ, Bacon BR, Gutnik SH, Wadiwala IM, McLaren C, Kalhan SC, Tavill AS: Immediate diagnostic criteria for bacterial infection of ascitic fluid. Gastroenterology (1986) 90:1247–1254

    Google Scholar 

  20. Hoefs JC: Diagnostic paracentesis: a potent clinical tool. Gastroenterology (1990) 98:230–236

    Google Scholar 

  21. Runyon BA, Hoefs JC: Ascitic fluid analysis in the differentiation of spontaneous bacterial peritonitis from gastrointestinal tract perforation into ascitic fluid. Hepatology (1984) 4:447–450

    Google Scholar 

  22. Runyon BA, Hoefs JC: Culture-negative neutrocytic ascites: a variant of spontaneous bacterial peritonitis. Hepatology (1984) 4:1209–1211

    Google Scholar 

  23. Runyon BA, Umland ET, Merlin T: Inoculation of blood culture bottles with ascitic fluid. Archives of Internal Medicine (1987) 147:73–75

    Google Scholar 

  24. Felisart J, Rimola A, Arroyo V, Perez-Ayuso RM, Quintero E, Gines P, Rodes J: Cefotaxime is more effective than is ampicillin-tobramycin in cirrhotics with severe infections, Hepatology (1985) 5:457–462

    Google Scholar 

  25. Rimola A, Salmeron JM, Clemente G, Rodrigo L, Obrador A, Miranda ML, Guarner C, Planas R, Sola R, Vargas V, Casafont F, Marco F, Navasa M, Banares R, Arroyo V, Rodes J: Two different dosages of cefotaxime in the treatment of spontaneous bacterial peritonitis in cirrhosis. Results of a prospective, randomized, multicenter study. Hepatology (1995) 21:674–679

    Google Scholar 

  26. Ariza J, Xiol X, Esteve M, Fernandez F, Linares J, Alonso T, Gudiol F: Aztreonam versus cefotaxime in the treatment of gram-negative bacterial peritonitis. Hepatology (1991) 14:91–98

    Google Scholar 

  27. Runyon BA, McHutchison JG, Antillon MR, Akriviadis EA, Montano AA: Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. Gastroenterology (1991) 100:1737–1742

    Google Scholar 

  28. Navasa M, Follo A, Llovet JM, Clemente G, Vargas V, Rimola A, Marco F, Guarner C, Forne M, Planas R, Banares R, Castells L, Jimenez de Anta MT, Arroyo V, Rodes J: Randomized, comparitive study of oral ofloxacin versus cefotaxime in spontaneous bacterial peritonitis. Gastroenterology (1996) 111:1011–1017

    Google Scholar 

  29. Weinstein MP, Iannini PB, Stratton CW, Eickhoff TC: Spontaneous bacterial peritonitis: a review of 28 cases with emphasis on improved survival and factors influencing prognosis. American Journal of Medicine (1978) 64:592–598

    Google Scholar 

  30. Gines P, Rimola A, Planas R, Vargas V, Marco F, Almela M, Forne M, Miranda ML, Llach J, Salmeron JM, Esteve M, Marques JM, Jimenez de Anta MT, Arroyo V, Rodes J: Norfloxacin prevents spontaneous bacterial peritonitis in cirrhosis: results of a double-blind, placebo- controlled trial. Hepatology (1990) 12:716–724

    Google Scholar 

  31. Rolachon A, Cordier L, Bacq Y, Nousbaum JB, Franza A, Paris JC, Fratte S, Bohn B, Kitmacher P, Stahl JP, Zarski JP: Ciprofloxacin and long-term prevention of spontaneous bacterial peritonitis: Results of a prospective controlled trial. Hepatology (1995) 22:1171–1174

    Google Scholar 

  32. Singh N, Gayowski T, Yu VL, Wagener MM: Trimethoprimsulfamethoxazole for the prevention of spontaneous bacterial peritonitis in cirrhosis: a randomized trial. Annals of Internal Medicine (1995) 122:595–598

    Google Scholar 

  33. Inadomi J, Sonnenberg A: Cost-analysis of prophylactic antibiotics in spontaneous bacterial peritonitis. Gastroenterology (1997) 113:1289–1294

    Google Scholar 

  34. Younossi ZM, McHutchison, Ganiats, TG: An economic analysis of norfloxacin prophylaxis against spontaneous bacterial peritonitis. Journal of Hepatology (1997) 27:295–298

    Google Scholar 

  35. Dupeyron C, Mangeney N, Sedrati L, Campillo B, Fouet P, Leluan G: Rapid emergence of quinolone resistance in cirrhotic patients terated with norfloxacin to prevent spontaneous bacterial peritonitis. Antimicrobial Agents and Chemotherapy (1994) 38:340–344

    Google Scholar 

  36. Llovet JM, Rodriguez-Iglesias P, Moitinho E, Planas R, Battaller R, Navasa M, Menacho M, Pardo A, Castells A, Cabre E, Arroyo V, Gassull MA, Rodes J: Spontaneous bacterial peritonitis in patients with cirrhosis undergoing selective intestinal decontamination. Journal of Hepatology (1997) 26:88–95

    Google Scholar 

  37. Dunn, DL, Barke RA, Ahrenholz DH, Humphrey EW, Simmons RL: The adjuvant effect of peritoneal fluid in experimental peritonitis: mechanism and clinical implications. Annals of Surgery (1984) 199:37–43

    Google Scholar 

  38. Hau T, Nelson, RD, Fiegel VD, Levenson R, Simmons RL: Mechanisms of the adjuvant action of hemoglobin in experimental peritonitis. 2 influence of hemoglobin on human leukocyte chemotaxis in vitro. Journal of Surgical Research (1977) 22:174–180

    Google Scholar 

  39. Patel RT, Deen KI, Youngs J, Warwick J, Keighley MR: Interleukin 6 is a prognostic indicator of outcome in severe intra-abdominal sepsis. British Journal of Surgery (1994) 81:1306–1308

    Google Scholar 

  40. Fugger R, Zadrobilek E, Gotzinger P, Klimann S, Rogy M, Winkler S, Andel H, Mittelbock M, Roth E, Schulz F, Fritsch A: Perioperative TNF alpha and IL-6 concentrations correlate with septic state, organ dysfunction, and APACHE II scores in intra-abdominal infections. European Journal of Surgery (1993) 159:525–529

    Google Scholar 

  41. Holzheimer RG, Schein M, Wittmann DH: Inflammatory response in peritoneal exudate and plasma of patients undergoing planned relaparotomy for severe secondary peritonitis. Archives of Surgery (1995) 130:1314–1320

    Google Scholar 

  42. Schein M, Wittmann DH, Holzheimer R, Condon RE: Hypothesis: Compartmentalization of cytokines in intraabdominal infection. Surgery (1996) 119:694–700

    Google Scholar 

  43. McCloskey RV, Straube RC, Sanders C, Smith S, Smith C, and the CHESS Trial Study Group: Treatment of septic shock with human monoclonal antibody HA-1A. Annals of Internal Medicine (1994) 121:1–5

    Google Scholar 

  44. Abraham, E, Wunderink R, Silverman H, Perl, TM, Nasraway S, Levy H, Bone R, Wenzel RP, Balk R, Allred R, Pennington JE, Wherry JC, and the TNF-a Sepsis Study Group: Efficacy and safety of monoclonal antibody to human tumor necrosis factor-a in patients with sepsis syndrome. Journal of the American Medical Association (1995) 273:934–941

    Google Scholar 

  45. Reinhart K, Wiegand-Lohnert C, Grimminger F, Kaul M, Withington S, Treacher D, Eckart J, Willatts S, Bouza C, Krausch D, Stockenhuber F, Eiselstein J, Daum L, Kempeni J, and the MAK 195F Sepsis Study Group: Assessment of the safety and efficacy of the monoclonal anti-tumor necrosis factor antibody-fragment, MAK 195F, in patients with sepsis and septic shock: a multicenter, randomized, placebocontrolled, dose-ranging study. Critical Care Medicine (1996) 24:733–742

    Google Scholar 

  46. Sheehan G, Harding G: Intraperitoneal infections. In: Finegold SM, George WL (eds) Anaerobic infections in humans. Academic Press, San Diego, 1988, p 349–384

    Google Scholar 

  47. Bennion RS, Baron EJ, Thompson JE, Downes J, Summanen P, Talan DA, Finegold SM: The bacteriology of gangrenous and perforated appendicitis-revisited. Annals of Surgery (1990) 211:165–171

    Google Scholar 

  48. Baron EJ, Bennion R, Thompson J, Strong C, Summanae P, McTeague M, Finegold SM: A microbiological comparison between acute and complicated appendicitis. Clinical Infectious Diseases (1992) 14:227–231

    Google Scholar 

  49. Solomkin JS, Dellinger EP, Christou NV, Busuttil RW: Results of a multicenter trial comparing imipenem/cilastatin to tobramycin/clindamycin for intra-abdominal infections. Annals of Surgery (1990) 211:581–591

    Google Scholar 

  50. Condon RE, Walker AP, Sirinek KR, White PW, Fabian TC, Nichols RL, Wilson SE: Meropenem versus tobramycin plus clidamycin for the treatment of intraabdominal infections: results of a prospective, randomized, double-blind clinical trial. Clinical Infectious Diseases (1995) 21:544–550

    Google Scholar 

  51. Dougherty SH, Sirinek KR, Schauer PR, Fink MP, Fabian TC, Martin DH, Wiedermann B: Ticarcillin/clavulanate compared with clindamycin/gentamycin (with or without ampicillin) for the treatment of intra-abdominal infections in pediatric and adult patients. American Surgeon (1995) 61:297–303

    Google Scholar 

  52. Solomkin JS, Reinhart HH, Dellinger EP, Bohnen JM, Rotstein OD, Vogel SB, Simms HH, Hill CS, Bjornson HS, Haverstock DC, Coulter HO, Echols RM, and the Intraabdominal Infection Study Group: Results of a randomized trial comparing sequential intravenous/oral treatment with ciprofloxacin plus metronidazole to imipenem/cilastatin for intra-abdominal infections. Annals of Surgery (1996) 223:303–315

    Google Scholar 

  53. Jousimies-Somer H: Recently described clinically important anaerobic bacteria: taxonomic aspect and update. Clinical Infectious Diseases (1997) 25, Supplement 2:78–87

    Google Scholar 

  54. Weinstein WM, Onderdonk AB, Bartlett JG, Gorbach SL: Experimental intra-abdominal abscesses in rats. I: Development of an experimental model. Infection and Immunity (1974) 10:1250–1255

    Google Scholar 

  55. Weinstein WM, Sullivan NM, Bartlett JG, Gorbach SL: Experimental intra-abdominal abscesses in rats. II: Quantitative bacteriology of infected animals. Infection and Immunity (1974) 10:1256–1259

    Google Scholar 

  56. Weinstein WM, Onderdonk AB, Bartlett JG, Louie TJ, Gorbach SL: Antimicrobial treatment of experimental intraabdominal sepsis. Journal of Infectious Diseases (1975) 132:282–286

    Google Scholar 

  57. Thadepalli H, Gorbach SL, Broido PW, Norsen J, Nyhus L: Abdominal trauma, anaerobes, and antibiotics. Surgery, Gynecology and Obstetrics (1973) 137:270–276

    Google Scholar 

  58. Burnett RJ, Haverstock DC, Patchen Dellinger E, Reinhart HH, Bohnen JM, Rotstein OD, Vogel SB, Solomkin JS: Definition of the role of enterococcus in intraabdominal infection: Analysis of a prospective randomized trial. Surgery (1995) 118:716–723

    Google Scholar 

  59. Sawyer RG, Adams RB, Rosenlof LK, May AK, Pruett TL: The role ofCandida albicans in the pathogenesis of experimental fungal/bacterial peritonitis and abscess formation. American Surgeon (1995) 61:726–731

    Google Scholar 

  60. Klaerner HG, Uknis ME, Acton RD, Dahlberg PS, Carlone-Jambor C, Dunn DL:Candida albicans andEschericia coli are synergistic pathogens during experimental microbial peritonitis. Journal of Surgical Research (1997) 70:161–165

    Google Scholar 

  61. Solomkin JS, Flohr AB, Quie PG, Simmons RL: The role ofCandida in intraperitoneal infections. Surgery (1980) 88:524–530

    Google Scholar 

  62. Calandra T, Bille J, Schneider R, Mosimann F, Francioli P: Clinical significance ofCandida isolated from peritoneum in surgical patients. Lancet (1989) 2:1437–1440

    Google Scholar 

  63. Montgomery RS, Wilson SE: Intraabdominal abscesses: image-guided diagnosis and therapy. Clinical Infectious Diseases (1996) 23:28–36

    Google Scholar 

  64. Smith JA, Skidmore AG, Forward AD, Clarke AM, Sutherland E: Prospective, randomized, double-blind comparison of metronidazole and tobramycin with clindamycin and tobramycin in the treatment of intra-abdominal sepsis. Annals of Surgery (1980) 192:213–220

    Google Scholar 

  65. Walker AP, Nichols RL, Wilson RF, Bivens BA, Trunkey DD, Edmiston CE, Smith JW, Condon RE: Efficacy of a b- lactamase inhibitor combination for serious intraabdominal infections. Annals of Surgery (1993) 217:115–121

    Google Scholar 

  66. Investigators of the Piperacillin/Tazobactam Intra-abdominal Infection Study Group: Results of the North American trial of piperacillin/tazobactam compared with clindamycin and gentamicin in the treatment of severe intra-abdominal infections. European Journal of Surgery (1994) Supplement 573:61–66

    Google Scholar 

  67. Brismar B, Malmborg AS, Tunevall G, Wretlin B, Bergman L, Mentzing LO, Nystrom PO, Kihlstrom E, Backstrand B, Skau T, Kasholm-Tengve B, Sjoberg L, Olsson-Liljequist B, Tally FP, Gatenbeck L, Eklund AE, Nord CE: Piperacillintazobactam versus imipenem-cilastatin for treatment of intraabdominal infections. Antimicrobial Agents and Chemotherapy (1992) 36:2766–2773

    Google Scholar 

  68. Kanellakopoulou K, Giamarellou H Papadothomakos P, Tsipras H, Chloroyiannis J Theakou R, Sfikakis P: Meropenem versus imipenem/cilastatin in the treatment of intraabdominal infections requiring surgery. European Journal of Clinical Microbiology & Infectious Diseases (1993) 12:449–453

    Google Scholar 

  69. Bourgeault AM, Lamothe F, Hoban DJ, Dalton MT, Kibsey PC, Harding G, Smith JA, Low DE, Gilbert H: Survey ofBacteroides fragilis group susceptibility patterns in Canada. Antimicrobial Agents and Chemotherapy (1992) 36:343–347

    Google Scholar 

  70. Hatala R, Dinh T, Cook DJ: Once-daily aminoglycoside dosing in immunocompetent adults: a meta-analysis. Annals of Internal Medicine (1996) 124:717–725

    Google Scholar 

  71. Bailey TC, Little JR, Littemberg B, Reichley RM, Dunagan WC: A meta-analysis of extended-interval dosing versus multiple daily dosing of aminoglycosides. Clinical Infectious Diseases (1997) 24:786–795

    Google Scholar 

  72. Ali MZ, Goetz MB: A meta-analysis of the relative efficacy and toxicity of single daily dosing versus multiple daily dosing of aminoglycosides. Clinical Infectious Diseases (1997) 24:796–809

    Google Scholar 

  73. Hatala R, Dinh TT, Cook DJ: Single daily dosing of aminoglycosides in immunosuppressed adults: a systematic review. Clinical Infectious Diseases (1997) 24:810–815

    Google Scholar 

  74. Bertino JS, Rotschafer JC: Single daily dosing of aminoglycosides - a concept whose time has not yet come. Clinical Infectious Diseases (1997) 24:820–823

    Google Scholar 

  75. Pitcher WD, Musher DM: Critical importance of early diagnosis and treatment of intra-abdominal infection. Archives of Surgery (1980) 117:328–333

    Google Scholar 

  76. Mosdell DM, Morris DM, Voltura M, Pitcher DE, Twiest MW, Milne RL, Miscall BG, Fry DE: Antibiotic treatment for surgical peritonitis. Annals of Surgery (1991) 214:543–549

    Google Scholar 

  77. Montravers P, Gauzit R, Muller C, Marmuse JP, Fichelle A, Desmonts JM: Emergence of antibiotic-resistant bacteria in cases of peritonitis after intraabdominal surgery affects the efficacy of empirical antimicrobial therapy. Clinical Infectious Diseases (1996) 23:486–494

    Google Scholar 

  78. Stone HH, Bourneuf AA, Stinson LD: Reliability of criteria for predicting persistent or recurrent sepsis. Archives of Surgery (1985) 120:17–20

    Google Scholar 

  79. Antimicrobial prophylaxis in surgery. Medical Letter (1997) 39:97–101

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Laroche, M., Harding, G. Primary and secondary peritonitis: An update. Eur. J. Clin. Microbiol. Infect. Dis. 17, 542–550 (1998). https://doi.org/10.1007/BF01708616

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF01708616

Keywords

Navigation