What is the difference between peritonitis and sepsis

Spontaneous bacterial peritonitis in adults: Diagnosis. Feehally J, et al. Complications of peritoneal dialysis. In: Comprehensive Clinical Nephrology. Salzer, WL. Peritoneal dialysis-related peritonitis: Challenges and solutions. International Journal of Nephrology and Renovascular Disease. Spontaneous bacterial peritonitis SBP. The Merck Manual Professional Edition. Greenberger NJ, et al. Burkart JM.

Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis. Risk factors and prevention of peritonitis in peritoneal dialysis. Li PK, et al. ISPD peritonitis recommendations: update on prevention and treatment. Peritoneal Dialysis International. Rajan E expert opinion. June 1, Ultrasonography and computed tomography have become essential diagnostic tools in abdominal sepsis.

The diagnostic approach to confirm the source of abdominal infection in septic patients depends largely on the haemodynamic stability of the patient [ 21 ]. Critically ill patients who are haemodynamically unstable or have developed severe acute respiratory distress syndrome ARDS requiring high-level ventilatory support, are at significant risk during transport to the radiology department In unstable patients who do not undergo an immediate laparotomy and whose critical condition prevents them from leaving ICU for further imaging, ultrasound US is the best available imaging modality [ 22 ].

It is portable, it can be performed at the bed side, it is reproducible and can be easily repeated. Major drawbacks are ileus and obesity, which may significantly mask the US view. US is also strongly operator-dependent. In suspected biliary sepsis US is always the preferred initial diagnostic modality for acute cholecystitis and emphysematous cholecystitis. In stable patients, abdominal computerized tomography CT is the imaging modality of choice, especially when the diagnosis is uncertain.

However, in patients with severe sepsis, if the diagnosis of peritonitis is made clinically or by previous radiological examinations plain films of the abdomen or US , additional CT scanning may be unnecessary and would only delay much-needed surgical intervention [ 22 ].

Another option in the diagnosis of critically ill patients suffering from intra-abdominal sepsis is bedside laparoscopy, as it can avoid patient transport to the radiological department or operating room is very accurate, and maintains ICU monitoring [ 23 ].

It may quickly provide the necessary information to address further management. However, the overall mortality of patients undergoing diagnostic laparoscopy in the ICU is high, regardless of diagnostic findings during this procedure. The use of diagnostic laparoscopy should be limited to patients in whom a therapeutic intervention is strongly suspected [ 24 ]. A key component of the first-line management of the septic patient is the administration of IV antimicrobial therapy.

Antimicrobial therapy plays a pivotal role in the management of intra-abdominal infections, especially in patients with severe sepsis who require immediate empiric antibiotic therapy.

An insufficient or otherwise inadequate antimicrobial regimen is one of the variables more strongly associated with unfavorable outcomes in critical ill patients [ 25 ]. Empiric antimicrobial therapy should be started as soon as possible in patients with severe sepsis with or without septic shock [ 26 — 28 ].

The role of the infecting pathogen on the patients response in secondary peritonitis has been poorly investigated. Contrastingly, others suggest that different types of pathogens may elicit various inflammatory responses, despite a common pathway of activation. Riche et al. The hypothesis that different types of pathogens may elicit various inflammatory responses, was already highlighted in animal models. In rats with peritonitis, Montravers et al. Evidence regarding a specific role of some pathogens on the pattern of the sepsis response is rather small, preventing any definitive conclusion from these results.

However it is well known that patients with severe sepsis or septic shock may benefit from aggressive antimicrobial treatment in order to curb the spread of the multiple organ dysfunction syndrome caused by an ongoing peritoneal trigger. For these patients, a de-escalated approach may be the most appropriate strategy.

Increasing rates of resistance and a more comprehensive understanding of the sepsis process have prompted many experts to advocate the use of broad-spectrum antimicrobial regimens in the initial stages of treatment for sepsis [ 34 , 35 ]. Subsequent modification de-escalation of the initial regimen becomes possible later, when culture results are available and clinical status can be better assessed, 48—72 hours after initiation of empiric therapy.

When treating abdominal sepsis, clinicians must be aware that drug pharmacokinetics may differ significantly between patients due to the variable pathophysiology of sepsis, and must also take into account the pathophysiological and immunological status of the patient [ 36 ]. Low plasma antimicrobial levels can contribute to lower than expected antimicrobial concentrations in peritoneal fluid with potentially reduced antimicrobial delivery to the target tissues.

If the Vd is enlarged the Ct will results in a lower than expected level with the standard LD [ 36 ]. Once appropriate initial loading is achieved, it is mandatory to reassess the antimicrobial regimen daily, because the pathophysiological changes that may occur, may significantly affect drug disposition in the critically ill patients.

Lower than standard dosages of renally excreted drugs must be administered in the presence of impaired renal function, while higher than standard dosages of renally excreted drugs may be needed for optimal exposure in patients with glomerular hyperfiltration [ 36 ]. In Table 1 recommended dosing regimens of the most frequently used renally excreted antimicrobials according to renal function are illustrated. Concentration-dependent antibiotics, such as aminoglycosides and quinolones, are more effective at higher concentrations.

They therefore feature a concentration-dependent post-antibiotic effect, and bactericidal action continues for a period of time after the antibiotic level falls below the minimum inhibitory concentration MIC [ 36 ]. Concentration-dependent agents administered in high dosage, short-course, once-a-day treatment regimens may promote more rapid and efficient bactericidal action and prevent the development of resistant strains. There is good evidence for extended duration of aminoglycoside dosing in critically ill patients.

In terms of toxicity, aminoglycosides nephrotoxicity is caused by a direct effect on the renal cortex and the uptake into the renal cortex can be saturated. Thus a dosing strategy of extended duration reduces the renal cortex exposure to aminoglycosides and reduces the risk of nephrotoxicity [ 37 ].

Unlike concentration-dependent agents, they have a negligible post-antibiotic effect. The efficacy of time-dependent antibacterial agents in severely ill patients is based on the constant maintenance of supra-inhibitory drug concentrations; as such, clinicians should consider multiple doses per day [ 38 ].

The empirically designed antimicrobial regimen is based on the underlying severity of infection, the pathogens presumed to be involved, and the risk factors indicative of major resistance patterns. Intra-abdominal infections in critically ill patients can be treated with either single or multiple antimicrobial regimens depending on the range requirements of antimicrobial coverage [ 40 ].

It is still a good antimicrobial agent in critically ill patients with community-acquired intra-abdominal infections. Carbapenems have a spectrum of antimicrobial activity that includes Gram-positive except resistant gram positive cocci and Gram-negative aerobic and anaerobic pathogens.

Doripenem seems more effective, in vitro, than meropenem and imipenem against Pseudomonas aeruginosa [ 44 ]. In the last few years carbapenem overuse has been associated with increasing rates of resistance among enterobacteriacea [ 45 ], particularly Klebsiella pneumonia. From an epidemiological point of view, it is necessary to control the spread of carbapenemase producing gram negative bacteria by optimization of carbepenems use. The use of carbapenems in critically ill patients is acceptable and well indicated.

Tigecycline represents a valid option for complicated intra-abdominal infections due to its favorable in vitro activity against enterococci, ESBL-producing strains of E. Tigecycline has showed also considerable antimicrobial activity against Acinetobacter spp [ 46 , 47 ].

It does not have in vitro activity towards Pseudomonas aeruginosa and Proteus mirabilis. Given its in vitro activity against multidrug resistant MDR bacteria, tigecycline represents an interesting treatment option for intra-abdominal infections at risk for MDR [ 48 ]. Recently, an analysis of clinical trials for both approved and unapproved indications for tigecycline including one trial on complicated intra-abdominal infections , showed an increased risk of death among patients receiving tigecycline.

This observation led to a FDA recommendation against the use of tigecycline in severe infections [ 49 ]. Because of its tissue penetration in peritoneal and soft tissues [ 50 ], tigecycline is a very useful drug used in peritoneal infections. In patients with severe sepsis or septic shock of abdominal origin, in which the inflammatory process extends to the circulatory system, tigecycline should always be associated with another antimicrobial.

Although the epidemiological role of candida species in intra-abdominal infections has not yet been conclusively defined by the medical community, the clinical role of candida is nevertheless significant given that invasive candidiasis is generally associated with poor clinical prognosis. However, the presence of Candida in patients with no signs of infection is considered a contaminant and may not require treatment.

Fluconazole has been widely used for the treatment of candidiasis since its approval by the FDA in The azoles act primarily by inhibiting the cytochrome Pdependent enzyme lanosterol alpha-demethylase, necessary for the conversion of lanosterol to ergosterol in the cellular membrane of fungi [ 51 ]. Most C. However, epidemiological data demonstrate that the frequency of Candida infections is rising, with an increase in the proportion of infections caused by non-albicans Candida species that are intrinsically resistant or variably susceptible to fluconazole [ 52 ].

Several randomized clinical trials have demonstrated the efficacy of the echinocandins in the treatment of candidaemia and invasive candidiasis [ 53 ].

The echinocandins: anidulafungin, caspofungin, and micafungin have a broad and similar spectrum of in vitro and in vivo activity against most Candida spp. Echinocandins have several potential advantages over fluconazole for the treatment of invasive candidiasis. They have a broader spectrum of activity encompassing fluconazole-resistant C.

In the specific setting of intra-abdominal infections, echinocandins are generally recommended as a first line empiric therapy for critical ill patients, while fluconazole is typically recommended for less severe cases [ 21 ]. One of the most likely explanations for the high morbidity and mortality rates associated with severe sepsis is the development of cardiovascular insufficiency, which can lead to global tissue hypoxia.

In severe sepsis, the early haemodynamic profile is characterized by hypovolaemia, vaso-regulatory dysfunction, and myocardial depression. Increased capillary leakage and venous capacitance ultimately result in decreased venous return to the heart. These haemodynamic alterations associated with the early stages of sepsis are often accompanied by an increase in systemic oxygen demand and impaired oxygen delivery, thereby inducing global tissue hypoxia.

Global tissue hypoxia may overstimulate endothelial cell activity, which can subsequently lead to the systemic inflammatory cascade characteristic of sepsis [ 56 , 57 ]. Early treatment with aggressive haemodynamic support can limit the damage of sepsis-induced tissue hypoxia and prevent the over stimulation of endothelial activity. Rivers et al. Lactate clearance has also been associated with decreased mortality in patients with severe sepsis and septic shock [ 64 ].

Fluid resuscitation is a major component of cardiovascular support in early sepsis. Although the need for fluid resuscitation in sepsis is well established, the goals and components of this treatment are still a matter of debate also in patients with peritonitis. The absence of clear benefits following the administration of colloid solutions compared to crystalloid [ 68 ], supports a high-grade recommendation for the use of crystalloid solutions in the initial resuscitation of patients with severe sepsis and septic shock [ 11 ].

In patients with generalized peritonitis, fluid resuscitation should be kept under control to avoid fluids overload, which may aggravate gut oedema and lead to increased intra-abdominal pressure.

Increasing intra-abdominal pressure causes progressive hypoperfusion of splanchnic circulation. Pathophysiological effects include gut oedema leading to bacterial translocation and release of cytokines, therefore aggravating the sepsis cascade [ 69 ]. Several studies have already shown that a positive fluid balance in critical illness may be strongly associated with a higher severity of organ dysfunction and with worse outcomes [ 70 ].

Pathophysiological mechanisms associated with the inflammatory response lead to capillary leakage. Although crystalloids are isotonic, a significant amount of the volume given may migrate into the extra-vascular space due to increased capillary permeability and changes in oncotic pressure.

In patient with severe generalized peritonitis excessive infusion of fluids may become a counterproductive strategy. The frequency with which intra-abdominal hypertension develops in abdominal sepsis may have other important clinical consequences in addition to its impact on sepsis resuscitation endpoints. However, in patients with severe sepsis or septic shock of abdominal origin, high intra-abdominal pressure may profoundly influence commonly used septic shock resuscitation endpoints such as CVP falsely elevated and urine output markedly decreased.

Repeated intravesical measurements of intra-abdominal pressure should be frequently performed in patients with severe sepsis or septic shock of abdominal origin, to identify patients at risk for intra-abdominal hypertension. Monitoring the fluid status of critically ill patients at risk for intra-abdominal hypertension is crucial. In recent decades we have witnessed rapid advances in fluid monitoring techniques. Pulmonary artery catheters PACs have been widely used for more than three decades, but their usefulness in improving patient outcomes seems disappointing.

Trials have consistently shown that PACs do no improve patient outcomes and may significantly increase medical costs [ 71 ]. With the declining use of PACs, there has been an increasing number of alternatives for hemodynamic monitoring.

Echocardiography is a useful noninvasive tool which can directly visualize the heart and assess cardiac function. Its use was long limited by the absence of accurate indices to diagnose hypovolemia and predict the effect of volume expansion.

In the last years echocardiography has been used to develop new parameters of fluid responsiveness, taking advantage of its ability to monitor cardiac function. Echocardiography has been shown to predict fluid responsiveness accurately and is now a complete and noninvasive tool able to accurately determine hemodynamic status in circulatory failure [ 72 , 73 ]. It is strongly operator-dependent, and it does not allow continuous monitoring.

It incorporates a transpulmonary thermodilution technique TPTD and continuous pulse contour analysis. It is minimally invasive and does not require intracardiac catheterization. It can give beat-by-beat monitoring of cardiac output, and can provide accurate information on volume status [ 74 ]. Vasopressor agents should be administered early in patients with severe sepsis or septic shock of abdominal origin to restore organ perfusion.

Their early use may prevent excessive fluid resuscitation. Vasopressor drugs maintain adequate blood pressure and preserve perfusion pressure thus optimizing blood flow in various organs. Norepinephrine is now the first-line vasopressor agent used to correct hypotension in the event of septic shock [ 11 ]. Norepinephrine is more efficacious than dopamine and may be more effective for reversing hypotension in patients with septic shock. In , Martin et al. The Surviving Sepsis Campaign guidelines favour norepinephrine [ 11 ] and there have been studies since the update to bolster this preference.

De Backer et al. It is well known that dopamine may cause more tachycardia and may be more arrhythmogenic than norepinephrine [ 77 ], and as an alternative vasopressor agent to norepinephrine, it should be used only in patients with low risk of tachyarrhythmias and absolute or relative bradycardia.

There are concerns regarding the use of epinephrine in septic patients due to its potential to decrease regional blood flow, particularly in the splanchnic circulation, and elevations in serum lactate. Peritonitis, a localized infection, may proceed to sepsis.

Both conditions may be difficult to diagnose. An injury or blockage may also perforate your bowel. Bowel contents can leak into your abdomen through the hole. This may cause a life-threatening infection. Sepsis Symptoms The first signs may include rapid breathing and confusion. Other common warning signs include: Fever and chills. Very low body temperature.

Since fever is a good indicator of infection, this information is valuable. Infections have a distinct, foul odor that's difficult to describe. Urine from patients with urinary tract infections smells extremely concentrated. A patient's breath may indicate a bowel obstruction when a fecal odor is present.

Peritonitis is often diagnosed by analyzing a sample of the infected fluid taken from the belly abdomen. Other tests for peritonitis may include: X-rays. Imaging tests that make pictures of your body's tissues, bones, and organs. Septic peritonitis is an inflammatory condition of the peritoneum that occurs secondary to microbial contamination.

This clinically important condition has a wide variety of clinical courses as well as high morbidity and mortality due to secondary multiorgan dysfunction. Antibiotics recommended in this setting include moxifloxacin, a combination of metronidazole with either levofloxacin or an oral cephalosporin, or amoxicillin-clavulanate. These oral agents can also be used for those who are treated in the outpatient setting but were initiated on inpatient IV therapy.

Peritonitis is common among people undergoing peritoneal dialysis therapy. Other medical conditions.