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Tertiary or recurrent peritonitis can occur after any operation for secondary bacterial peritonitis. The major risk factors for the development of tertiary peritonitis include malnutrition, a high Acute Physiology and Chronic Health Evaluation II score, the presence of organisms resistant to antimicrobial therapy, and organ system failure. Most patients with tertiary peritonitis will have fever and leukocytosis, even though other signs of infection may be absent. The management of tertiary peritonitis should include the provision of appropriate physiologic support, the administration of antimicrobial therapy, and operation or intervention to control the source of contamination and to decrease the bacterial load. Antibiotic-resistant organisms and bacteremia are present more commonly and mortality is greater in patients with tertiary peritonitis. Early recognition and effective intervention are critical to achieving a successful outcome.
TERTIARY PERITONITIS IS A recurrent infection of the peritoneal cavity following an episode of primary or secondary peritonitis. "Tertiary peritonitis" and "recurrent peritonitis" are synonymous terms. Both recurrent primary peritonitis and chronic ambulatory peritoneal dialysis (CAPD) catheter-related peritonitis are distinct clinical conditions that are frequently managed without operation and have microbiology that is very different from the majority of patients with tertiary peritonitis. This review will omit patients with recurrent primary peritonitis and CAPD catheter-related peritonitis and will exclusively address recurrent peritonitis following an episode of secondary bacterial infection of the peritoneal cavity. This situation presents significant challenges in recognition and management.
The appendix is the most common anatomic site of origin for secondary bacterial peritonitis. Less common sources for secondary peritonitis are the upper (stomach and duodenum) and lower (colon) gastrointestinal tracts. In contrast, patients with tertiary peritonitis frequently have contamination that emanates from lower gastrointestinal tract and upper gastrointestinal tract sites with near equal frequency. Both of these are more common sources of tertiary peritonitis than are infections emanating from the appendix. Intraperitoneal infection also can develop after an elective abdominal operation. The pathogenesis of bacterial peritonitis is highly dependent on (1) the degree of bacterial contamination, sometimes referred to as the bacterial load; (2) the virulence of the bacteria involved and the synergistic effects of multiple bacterial species; (3) the presence of adjuvants for bacterial growth such as intestinal contents, inert materials (e.g., barium), fibrin, and foreign bodies; (4) the adequacy of...