[Post-operative peritonitis. Surgical tactics and antibiotic therapy]

Despite progress in general supportive measures the mortality in post-operative peritonitis remains high (around 50%). Reoperation and antimicrobial therapy are two major steps in the care of such patients. Reoperation should be considered on clinical grounds. Its major aim is to suppress the source of peritoneal infection, usually in this setting a breach in intestinal integrity. This is best achieved by temporary cutaneous enterostomy. Thorough peritoneal lavage is mandatory to ensure the removal of all particulate matter and pus. The procedure is ended by wound closing, leaving the skin layer open. Very infrequently, laparostomy has to be performed, either because of necrotizing wound infection, or deliberately, in face of peritoneal failure. If possible, when rapid healing permits delayed wound closure, laparostomy should be temporary. Antimicrobial therapy is started preferably with or just before reoperation, and is aimed at the known pathogens in post-operative abdominal sepsis, namely Bacteroïdes fragilis and enterobacteriaceae. A combination of nitro-imidazole and aminoglycoside or 3rd generation cephalosporin appears suitable in most cases. The duration of antimicrobial therapy is difficult to define at present but it should at least encompass the operation itself and the following 48 hours. The value of more prolonged use has not yet been established.