Gnocchi C A
Departamento de Medicina, Hospital de Clínicas José de San Martín, Facultad de Medicina, Universidad de Buenos Aires, Argentina.
Medicina (B Aires). 1999;59 Suppl 1:47-54.
Intra-abdominal infection is defined as the presence of an infectious process within the peritoneal cavity. It may be local or have a systemic consequence generating multiple organic disfunction. Most of the studies report a mortality of 30% in severe intra-abdominal infection. Secondary peritonitis is caused by the loss of integrity of the gastrointestinal apparatus, which contaminates with pathogens the peritoneal cavity. Invariably they are polymicrobial infections, mostly due to facultative anaerobic and anaerobic Gram negative bacilli. Prognosis of peritonitis depends on the struggle between two forces: local and systemic immunity of the host and the volume, nature and length of the contamination. Microorganisms and their products estimulate cellular defenses in the host and activate numerous inflammatory mediators responsible for sepsis. Antibiotic treatment of secondary peritonitis must act mainly against Escherichia coli and Bacteroides fragilis. The adequate and early empirical administration of antibiotics against these bacteria is well established. It is necessary to consider if the infection is localized or generalized and if it is accompanied or not by organic disfunction. It also has to be taken into account if peritonitis is community or hospital-acquired when choosing the antibiotic scheme. In community-acquired peritonitis with low to moderate infections a combination of metronidazole-ceftriaxone, metronidazole-gentamycin or a monodrug like ampicillin-sulbactam may be used. In severe hospital-acquired peritonitis imipenem or the combination piperacillin-tazobactam are effective. New quinolones such as trovafloxacin or clinafloxacin, with excellent activity against aerobes and anaerobes producing intra-abdominal infections, may be effective. Future clinical trials are needed to determine their utility. Tertiary peritonitis represent a systemic inflammatory response with multiorganic failure due to the uncontrolled activation of the inflammatory cascade. It is considered a persistent, systemic peritoneal inflammation. Antibiotics and new surgery do not seem to be useful in this situation.
腹腔内感染被定义为腹膜腔内存在感染过程。它可能是局部性的，也可能产生全身影响，导致多器官功能障碍。大多数研究报告称，严重腹腔内感染的死亡率为30%。继发性腹膜炎是由胃肠道结构完整性丧失引起的，病原体由此污染腹膜腔。这些感染无一例外都是多微生物感染，主要由兼性厌氧菌和厌氧革兰氏阴性杆菌引起。腹膜炎的预后取决于两种力量的较量：宿主的局部和全身免疫力，以及污染的量、性质和持续时间。微生物及其产物刺激宿主的细胞防御，并激活众多导致败血症的炎症介质。继发性腹膜炎的抗生素治疗必须主要针对大肠杆菌和脆弱拟杆菌。针对这些细菌进行充分且早期的经验性抗生素给药已得到充分确立。有必要考虑感染是局限性的还是全身性的，以及是否伴有器官功能障碍。在选择抗生素方案时，还必须考虑腹膜炎是社区获得性的还是医院获得性的。对于社区获得性、低至中度感染的腹膜炎，可使用甲硝唑 - 头孢曲松、甲硝唑 - 庆大霉素联合用药，或氨苄西林 - 舒巴坦等单一药物。对于严重的医院获得性腹膜炎，亚胺培南或哌拉西林 - 他唑巴坦联合用药有效。新型喹诺酮类药物，如曲伐沙星或克林沙星，对引起腹腔内感染的需氧菌和厌氧菌具有出色活性，可能有效。需要未来的临床试验来确定它们的效用。三期腹膜炎表现为由于炎症级联反应失控而导致多器官功能衰竭的全身炎症反应。它被认为是一种持续性的全身性腹膜炎症。在这种情况下，抗生素和新的手术似乎都没有用。
