Skip to main content
SpringerLink
Log in

Quoi de neuf dans la prise en charge des péritonites postopératoires

Update on the management of postoperative peritonitis

  • Mise au Point / Update
  • Published:
Réanimation

Résumé

Les péritonites postopératoires correspondent à une infection de la cavité péritonéale au décours d’une précédente chirurgie abdominale. Les causes les plus fréquentes sont un lâchage de suture, une perforation du tube digestif ou un (ou plusieurs) abcès. Les germes impliqués sont des germes aérobies à Gram négatif (entérobactéries et bacilles non fermentants) et à Gram positif (streptocoques, staphylocoques et entérocoques), des bactéries anaérobies (principalement bactéroïdes et clostridium) et des levures de type candida. Ces micro-organismes sont souvent résistants aux antibiotiques, voire multirésistants. La prise en charge de ces affections est une urgence thérapeutique. Le diagnostic est souvent difficile reposant sur un faisceau d’arguments. La tomodensitométrie (TDM) est l’examen de référence. Les autres examens, y compris biologiques, ne sont utiles que pour établir le retentissement de l’infection. Le traitement est chirurgical et médical. Le traitement étiologique repose sur la chirurgie pour identifier et éliminer la cause de l’infection, réaliser des prélèvements microbiologiques, effectuer une toilette péritonéale et prévenir la récidive. Le traitement médical symptomatique prend en charge les conséquences de l’infection. Le traitement antibiotique est dirigé contre les germes isolés des prélèvements opératoires. Une antibiothérapie ne prenant pas en compte tous les germes isolés et une prise en charge tardive sont des facteurs d’échec thérapeutique, de persistance de l’infection, voire de décès. La durée du traitement est de l’ordre de 7 à 15 jours.

Abstract

Postoperative peritonitis is defined as an infection of the peritoneal space following an initial abdominal surgery. The main causes are suture leaks, bowel perforation and one or several abscesses. The cultured microorganisms are Gram negative aerobes (Enterobacteriaceae and nonfermenting bacilli), Gram positive aerobes (streptococci, staphylococci, and enterococci), anaerobes (mainly bacteroides and clostridia), and fungi (essentially candidas). These organisms are frequently resistant to antibiotics or even multidrug resistant. The management of these complications is a therapeutic emergency. Diagnosis is often difficult and based on a body of evidence. CT scan is the key imaging technique. The other routine tests, including biological tests, are used only to assess the severity of the infection. Treatment is based on both surgical and medical management. Surgery is the etiological approach to identify and eliminate the source of infection, to draw microbiological samples, to perform an extensive peritoneal cleaning, and to avoid relapse. The medical management is based on supportive care. The antibiotic therapy is focused against the organisms cultured from surgical samples. Inadequate antibiotic therapy not targeting all the cultured pathogens is a risk factor of therapeutic failure, persisting infection or even death. The recommended duration of antibiotic therapy stands between 7 and 15 days.

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

Access this article

Log in via an institution

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

Instant access to the full article PDF.

Institutional subscriptions

Références

  1. Laterre PF, Colardyn F, Delmee M, et al (2006) Antimicrobial therapy for intra-abdominal infections: guidelines from the Infectious Disease Advisory Board (IDAB). Acta Chir Belg 106:2–21

    CAS  PubMed  Google Scholar 

  2. Guirao X, Arias J, Badia JM, et al (2009) Recommendations in the empiric anti-infective agents of intra-abdominal infection. Rev Esp Quimioter 22:151–72

    CAS  PubMed  Google Scholar 

  3. Solomkin JS, Mazuski JE, Bradley JS, et al (2010) Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 50:133–64

    Article  PubMed  Google Scholar 

  4. Chow AW, Evans GA, Nathens AB, et al (2010) Canadian practice guidelines for surgical intra-abdominal infections. Can J Infect Dis Med Microbiol 21:11–37

    PubMed  PubMed Central  Google Scholar 

  5. Bodmann KF (2010) Complicated intra-abdominal infections: pathogens, resistance. Recommendations of the Infectliga on antbiotic therapy. Chirurg 81:38–49

    Article  PubMed  Google Scholar 

  6. Sartelli M, Viale P, Catena F, et al (2013) 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg 8:3

    Article  PubMed  PubMed Central  Google Scholar 

  7. Montravers P, Dupont H, Leone M, et al (2015) Guidelines for management of intra-abdominal infections. Anaesth Crit Care Pain Med 34:117–30

    Article  PubMed  Google Scholar 

  8. Panhofer P, Izay B, Riedl M, et al (2009) Age, microbiology and prognostic scores help to differentiate between secondary and tertiary peritonitis. Langenbecks Arch Surg 394:265–71

    Article  PubMed  Google Scholar 

  9. Weiss G, Meyer F, Lippert H (2006) Infectiological diagnostic problems in tertiary peritonitis. Langenbecks Arch Surg 391:473–82

    Article  CAS  PubMed  Google Scholar 

  10. Chromik AM, Meiser A, Holling J, et al (2009) Identification of patients at risk for development of tertiary peritonitis on a surgical intensive care unit. J Gastrointest Surg 13:1358–67

    Article  PubMed  Google Scholar 

  11. Montravers P, Dufour G, Guglielminotti J, et al (2015) Dynamic changes of microbial flora and therapeutic consequences in persistent peritonitis. Crit Care 19:70

    Article  PubMed  PubMed Central  Google Scholar 

  12. Montravers P, Augustin P, Zappella N, et al (2015) Diagnosis and management of the postoperative surgical and medical complications of bariatric surgery. Anaesth Crit Care Pain Med 34:45–52

    Article  PubMed  Google Scholar 

  13. Holzheimer RG, Gathof B (2003) Re-operation for complicated secondary peritonitis-how to identify patients at risk for persistent sepsis. Eur J Med Res 8:125–34

    CAS  PubMed  Google Scholar 

  14. Kermarrec N, Marmuse JP, Faivre J, et al (2008) High mortality rate for patients requiring intensive care after surgical revision following bariatric surgery. Obes Surg 18:171–8

    Article  PubMed  Google Scholar 

  15. Montravers P, Guglielminotti J, Zappella N, et al (2013) Clinical features and outcome of postoperative peritonitis following bariatric surgery. Obes Surg 23:1536–44

    Article  PubMed  PubMed Central  Google Scholar 

  16. van Ruler O, Lamme B, Gouma DJ, et al (2007) Variables associated with positive findings at relaparotomy in patients with secondary peritonitis. Crit Care Med 35:468–76

    Article  PubMed  Google Scholar 

  17. van Ruler O, Kiewiet JJ, Boer KR, et al (2011) Failure of available scoring systems to predict ongoing infection in patients with abdominal sepsis after their initial emergency laparotomy. BMC Surg 11:38

    Article  PubMed  PubMed Central  Google Scholar 

  18. Paugam-Burtz C, Dupont H, Marmuse JP, et al (2002) Daily organ-system failure for diagnosis of persistent intra-abdominal sepsis after postoperative peritonitis. Intensive Care Med 28:594–8

    Article  CAS  PubMed  Google Scholar 

  19. Paugam-Burtz C, Mantz J, Dupont H, et al (2007) Procalcitonin levels and sequential organ failure assessment scores in secondary peritonitis. Arch Surg 142:803; author reply 03–4

    Article  PubMed  Google Scholar 

  20. Jung B, Molinari N, Nasri M, et al (2013) Procalcitonin biomarker kinetics fails to predict treatment response in perioperative abdominal infection with septic shock. Crit Care 17:R255

    Article  PubMed  PubMed Central  Google Scholar 

  21. Rau BM, Frigerio I, Buchler MW, et al (2007) Evaluation of procalcitonin for predicting septic multiorgan failure and overall prognosis in secondary peritonitis: a prospective, international multicenter study. Arch Surg 142:134–42

    Article  CAS  PubMed  Google Scholar 

  22. Dupont H, Carbon C, Carlet J (2000) Monotherapy with a broadspectrum beta-lactam is as effective as its combination with an aminoglycoside in treatment of severe generalized peritonitis: a multicenter randomized controlled trial. The Severe Generalized Peritonitis Study Group. Antimicrob Agents Chemother 44:2028–33

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Montravers P, Lepape A, Dubreuil L, et al (2009) Clinical and microbiological profiles of community-acquired and nosocomial intra-abdominal infections: results of the French prospective, observational EBIIA study. J Antimicrob Chemother 63:785–94

    Article  CAS  PubMed  Google Scholar 

  24. Riche FC, Dray X, Laisne MJ, et al (2009) Factors associated with septic shock and mortality in generalized peritonitis: comparison between community-acquired and postoperative peritonitis. Crit Care 13:R99

    Article  PubMed  PubMed Central  Google Scholar 

  25. Augustin P, Kermarrec N, Muller-Serieys C, et al (2010) Risk factors for multidrug resistant bacteria and optimization of empirical antibiotic therapy in postoperative peritonitis. Crit Care 14:R20

    Article  PubMed  PubMed Central  Google Scholar 

  26. Seguin P, Fedun Y, Laviolle B, et al (2010) Risk factors for multidrug-resistant bacteria in patients with post-operative peritonitis requiring intensive care. J Antimicrob Chemother 65:342–6

    Article  CAS  PubMed  Google Scholar 

  27. Seguin P, Laviolle B, Chanavaz C, et al (2006) Factors associated with multidrug-resistant bacteria in secondary peritonitis: impact on antibiotic therapy. Clin Microbiol Infect 12:980–5

    Article  CAS  PubMed  Google Scholar 

  28. Swenson BR, Metzger R, Hedrick TL, et al (2009) Choosing antibiotics for intra-abdominal infections: what do we mean by “high risk”? Surg Infect (Larchmt) 10:29–39

    Article  Google Scholar 

  29. De Ruiter J, Weel J, Manusama E, et al (2009) The epidemiology of intra-abdominal flora in critically ill patients with secondary and tertiary abdominal sepsis. Infection 37:522–7

    Article  PubMed  Google Scholar 

  30. Dupont H, Vael C, Muller-Serieys C, et al (2008) Prospective evaluation of virulence factors of enterococci isolated from patients with peritonitis: impact on outcome. Diagn Microbiol Infect Dis 60:247–53

    Article  PubMed  Google Scholar 

  31. Seguin P, Brianchon C, Launey Y, et al (2012) Are enterococci playing a role in postoperative peritonitis in critically ill patients? Eur J Clin Microbiol Infect Dis 31:1479–85

    Article  CAS  PubMed  Google Scholar 

  32. Dupont H, Paugam-Burtz C, Muller-Serieys C, et al (2002) Predictive factors of mortality due to polymicrobial peritonitis with Candida isolation in peritoneal fluid in critically ill patients. Arch Surg 137:1341–6; (discussion 47)

    Article  PubMed  Google Scholar 

  33. Montravers P, Mira JP, Gangneux JP, et al (2011) A multicentre study of antifungal strategies and outcome of Candida spp. peritonitis in intensive-care units. Clin Microbiol Infect 17:1061–7

    Article  CAS  PubMed  Google Scholar 

  34. Zappella N, Desmard M, Chochillon C, et al (2015) Positive peritoneal fluid fungal cultures in postoperative peritonitis after bariatric surgery. Clin Microbiol Infect 21:853e1–e3

    Article  Google Scholar 

  35. Leon C, Ruiz-Santana S, Saavedra P, et al (2006) A bedside scoring system (“Candida score”) for early antifungal treatment in nonneutropenic critically ill patients with Candida colonization. Crit Care Med 34:730–7

    Article  PubMed  Google Scholar 

  36. Dupont H, Bourichon A, Paugam-Burtz C, et al (2003) Can yeast isolation in peritoneal fluid be predicted in intensive care unit patients with peritonitis? Crit Care Med 31:752–7

    Article  PubMed  Google Scholar 

  37. Bedikian A, Okamoto MP, Nakahiro RK, et al (1994) Pharmacokinetics of meropenem in patients with intra-abdominal infections. Antimicrob Agents Chemother 38:151–4

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Karjagin J, Lefeuvre S, Oselin K, et al (2008) Pharmacokinetics of meropenem determined by microdialysis in the peritoneal fluid of patients with severe peritonitis associated with septic shock. Clin Pharmacol Ther 83:452–9

    Article  CAS  PubMed  Google Scholar 

  39. Seguin P, Verdier MC, Chanavaz C, et al (2009) Plasma and peritoneal concentration following continuous infusion of cefotaxime in patients with secondary peritonitis. J Antimicrob Chemother 63:564–7

    Article  CAS  PubMed  Google Scholar 

  40. Buijk SL, Gyssens IC, Mouton JW, et al (2002) Pharmacokinetics of ceftazidime in serum and peritoneal exudate during continuous versus intermittent administration to patients with severe intraabdominal infections. J Antimicrob Chemother 49:121–8

    Article  CAS  PubMed  Google Scholar 

  41. Hites M, Taccone FS, Wolff F, et al (2013) Case-control study of drug monitoring of beta-lactams in obese critically ill patients. Antimicrob Agents Chemother 57:708–15

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Grau S, Luque S, Campillo N, et al (2015) Plasma and peritoneal fluid population pharmacokinetics of micafungin in postsurgical patients with severe peritonitis. J Antimicrob Chemother 70:2854–61

    Article  CAS  PubMed  Google Scholar 

  43. Sartelli M, Abu-Zidan FM, Ansaloni L, et al (2015) The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper. World J Emerg Surg 10:35

    Article  PubMed  PubMed Central  Google Scholar 

  44. van Ruler O, Mahler CW, Boer KR, et al (2007) Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA 298:865–72

    Article  PubMed  Google Scholar 

  45. Kirkpatrick AW, Roberts DJ, De Waele J, et al (2013) Intraabdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 39:1190–206

    Article  PubMed  PubMed Central  Google Scholar 

  46. Dupont H, Friggeri A, Touzeau J, et al (2011) Enterococci increase the morbidity and mortality associated with severe intra-abdominal infections in elderly patients hospitalized in the intensive care unit. J Antimicrob Chemother 66:2379–85

    Article  CAS  PubMed  Google Scholar 

  47. Gauzit R, Pean Y, Barth X, et al (2009) Epidemiology, management, and prognosis of secondary non-postoperative peritonitis: a French prospective observational multicenter study. Surg Infect (Larchmt) 10:119–27

    Article  Google Scholar 

  48. Babinchak T, Ellis-Grosse E, Dartois N, et al (2005) The efficacy and safety of tigecycline for the treatment of complicated intraabdominal infections: analysis of pooled clinical trial data. Clin Infect Dis 41:S354–S67

    Article  CAS  PubMed  Google Scholar 

  49. Chen Z, Wu J, Zhang Y, et al (2010) Efficacy and safety of tigecycline monotherapy vs. imipenem/cilastatin in Chinese patients with complicated intra-abdominal infections: a randomized controlled trial. BMC Infect Dis 10:217

    Article  PubMed  PubMed Central  Google Scholar 

  50. Eckmann C, Montravers P, Bassetti M, et al (2013) Efficacy of tigecycline for the treatment of complicated intra-abdominal infections in real-life clinical practice from five European observational studies. J Antimicrob Chemother 68:ii25–ii35

    Article  CAS  PubMed  Google Scholar 

  51. Montravers P, Dupont H, Gauzit R, et al (2006) Candida as a risk factor for mortality in peritonitis. Crit Care Med 34:646–52

    Article  PubMed  Google Scholar 

  52. Bassetti M, Righi E, Ansaldi F, et al (2015) A multicenter multinational study of abdominal candidiasis: epidemiology, outcomes and predictors of mortality. Intensive Care Med 41:1601–10

    Article  PubMed  Google Scholar 

  53. Leon C, Ruiz-Santana S, Saavedra P, et al (2012) Value of beta- D-glucan and Candida albicans germ tube antibody for discriminating between Candida colonization and invasive candidiasis in patients with severe abdominal conditions. Intensive Care Med 38:1315–25

    Article  CAS  PubMed  Google Scholar 

  54. Tissot F, Lamoth F, Hauser PM, et al (2013) Beta-glucan antigenemia anticipates diagnosis of blood culture-negative intraabdominal candidiasis. Am J Respir Crit Care Med 188:1100–9

    Article  PubMed  Google Scholar 

  55. Martin-Mazuelos E, Loza A, Castro C, et al (2015) Beta-D-glucan and Candida albicans germ tube antibody in ICU patients with invasive candidiasis. Intensive Care Med 41:1424–32

    Article  CAS  PubMed  Google Scholar 

  56. Bassetti M, Marchetti M, Chakrabarti A, et al (2013) A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts. Intensive Care Med 39:2092–106

    Article  PubMed  Google Scholar 

  57. Pappas PG, Kauffman CA, Andes DR, et al (2015) Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis (en cours de publication)

    Google Scholar 

  58. Senn L, Eggimann P, Ksontini R, et al (2009) Caspofungin for prevention of intra-abdominal candidiasis in high-risk surgical patients. Intensive Care Med 35:903–8

    Article  PubMed  Google Scholar 

  59. Knitsch W, Vincent JL, Utzolino S, et al (2015) A randomized, placebo-controlled trial of preemptive antifungal therapy for the prevention of invasive candidiasis following gastrointestinal surgery for intra-abdominal infections. Clin Infect Dis 61:1671–8

    PubMed  PubMed Central  Google Scholar 

  60. Sawyer RG, Claridge JA, Nathens AB, et al (2015) Trial of shortcourse antimicrobial therapy for intraabdominal infection. N Engl J Med 372:1996–2005

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Département d’anesthésie-réanimation, CHU Bichat–Claude-Bernard, Assistance publique–Hôpitaux de Paris, HUPNVS, 46, rue Henri-Huchard, F-75018, Paris, France

    P. Montravers, B. Lortat-Jacob, A. Snauwaert, M. BenRehouma & E. Guivarch

  2. PRES Sorbonne Cité, Université Denis-Diderot, Paris, France

    P. Montravers & M. BenRehouma

  3. Service de chirurgie digestive et viscérale, CHU Bichat–Claude-Bernard, Assistance publique–Hôpitaux de Paris, HUPNVS, 46, rue Henri-Huchard, F-75018, Paris, France

    L. Ribeiro-Parenti

Authors
  1. P. Montravers
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. B. Lortat-Jacob
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. A. Snauwaert
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. M. BenRehouma
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. E. Guivarch
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. L. Ribeiro-Parenti
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to P. Montravers.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Montravers, P., Lortat-Jacob, B., Snauwaert, A. et al. Quoi de neuf dans la prise en charge des péritonites postopératoires. Réanimation 25, 274–286 (2016). https://doi.org/10.1007/s13546-016-1174-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13546-016-1174-7

Mots clés

Keywords

Search

Navigation