137.1 🎓 醫孞生版

137.1.0.1 📌 䞀頁重點

  • Peritonitis 䞉類:
    • Primary (SBP): 自癌, 倚 cirrhotic ascites; single organism (E. coli, Klebsiella, S. pneumoniae)
    • Secondary: hollow viscus 穿孔 (appendix, diverticulum, ulcer, ischemia); polymicrobial
    • Tertiary: persistent / recurrent after 治療 (multidrug-resistant, fungal)
  • 腹腔膿瘍: subphrenic, subhepatic, paracolic, pelvic — drainage + antibiotic
  • 病原 (secondary): mixed aerobic + anaerobic (E. coli, Klebsiella, Enterococcus, Bacteroides fragilis)
  • Empirical: Pip-tazo OR Ceftriaxone + Metronidazole OR Carbapenem (severe)
  • Source control = drainage / surgery — mandatory, antibiotics 單獚䞍倠

137.1.0.2 1⃣ Primary Peritonitis (SBP)

137.1.0.2.1 Spontaneous Bacterial Peritonitis
  • 倚 cirrhotic ascites (~ 10% admitted cirrhotic)
  • Without obvious source — translocation from gut
  • Single organism: E. coli > Klebsiella > S. pneumoniae > Enterococcus
  • Diagnosis:
    • Ascitic fluid PMN ≥ 250/ÎŒL (paracentesis)
    • Culture positive (~ 60% only)
  • Treatment:
    • Ceftriaxone 2 g IV daily × 5 days
    • Albumin 1.5 g/kg day 1 + 1 g/kg day 3 (prevent hepatorenal syndrome)
  • Prophylaxis:
    • Primary: norfloxacin / ciprofloxacin for high-risk cirrhosis (䜎 protein, varices bleeding, prior SBP)
    • Rifaximin alternative
137.1.0.2.2 Peritoneal Dialysis Peritonitis
  • PD catheter infection
  • Diagnosis: cloudy effluent + PMN ≥ 100/ÎŒL + 50% PMN
  • Empirical (intraperitoneal): vancomycin + ceftazidime OR cefepime
  • Catheter removal if refractory

137.1.0.3 2⃣ Secondary Peritonitis

137.1.0.3.1 Causes
  • Appendicitis (perforated)
  • Diverticulitis with perforation
  • Peptic ulcer perforation
  • Bowel ischemia / necrosis
  • Post-op anastomotic leak
  • Cholecystitis / cholangitis (sometimes 1° or 2°)
  • Penetrating trauma
137.1.0.3.2 病原 (Mixed)
  • Aerobic GN: E. coli, Klebsiella, Enterobacter, Proteus
  • Aerobic GP: Streptococcus, Enterococcus (selected)
  • Anaerobic: Bacteroides fragilis (#1), Prevotella, Peptostreptococcus, Clostridium
137.1.0.3.3 Empirical Treatment
嚎重床 治療
Mild-moderate community Ceftriaxone + Metronidazole OR Ertapenem OR Moxifloxacin + Metronidazole
Severe / ICU / health-care associated Pip-tazo OR Cefepime + Metronidazole OR Meropenem
Very severe / failed empirical Carbapenem + Vancomycin + 考慮 candin (anti-fungal)
137.1.0.3.4 Duration
  • 4 days post source control (STOP-IT trial 2015): non-inferior to longer course
  • 7-14 days if 䞍胜 adequate source control
137.1.0.3.5 Source Control
  • Surgery / IR drainage: NECESSARY
  • 越早越奜 (< 24 hr)

137.1.0.4 3⃣ 腹腔內膿瘍 Specific Locations

137.1.0.4.1 Hepatic Abscess
  • Pyogenic (#1): biliary > portal > hematogenous; K. pneumoniae in Taiwan/Asia (hypervirulent strain → 県、肺、CNS 蜉移); E. coli, Streptococcus, anaerobes
  • Amebic: E. histolytica (travel); single right lobe, “anchovy paste”; serology +
  • Tx: drainage (US/CT-guided) + antibiotics (pip-tazo or carbapenem) × 4-6 wks; amebic → metronidazole + luminal agent
137.1.0.4.2 Splenic Abscess
  • 倚 hematogenous (IE)
  • Streptococcus, S. aureus, Salmonella, fungi (immunocompromised)
  • Splenectomy often required (small ones drain)
137.1.0.4.3 Subphrenic / Subhepatic
  • Post-op or pneumonia spread
  • CT-guided percutaneous drain + antibiotics
137.1.0.4.4 Pelvic Abscess
  • 女性: tubo-ovarian abscess (PID complication)
  • 男女: post-op, perforated appendicitis
  • CT-guided drainage; clinda + gent or pip-tazo