DiPiro J T, Mansberger J A, Davis J B
Clin Pharm. 1986 Jan;5(1):34-50.
The etiology, pathophysiology, clinical presentation, and treatment of the two major types of intra-abdominal infections--peritonitis and abscesses--are described. Peritonitis of infectious origin is the acute response of the peritoneum to microorganisms; it is classified as primary (when the source of bacteria is not apparent) or secondary (usually involving perforation of a hollow structure of the GI tract with subsequent release of microbes). Peritonitis results in mortality because of fluid shifts and endotoxins that may cause hypovolemia and shock. Abscesses, purulent collections of fluid physically separated from the surrounding tissues, are the result of chronic inflammation following failure of the body to eradicate a pathogen completely. Secondary intra-abdominal infections are often polymicrobial because of the diversity of organisms in the GI tract. The size of bacterial inocula and the number and types of species present substantially affect patient outcome. The patient with peritonitis usually presents in acute distress, with generalized abdominal pain and faint bowel sounds. The presentation of the patient with intra-abdominal abscess is more variable and less dramatic; pain and fever may be present. The treatment of these infections requires the coordinated use of prompt surgical intervention, support of vital functions, and appropriate antimicrobial therapy. Surgical procedures are used to stop continuing bacterial contamination of the peritoneum, remove foreign material from the abdomen, and drain purulent collections; it is the foundation of treating most types of intra-abdominal infections. Aggressive fluid therapy is required to assure adequate intravascular volumes in most patients. Generally, antimicrobial coverage for both aerobes and anaerobes must be started before culture results are available. Antimicrobial therapy for specific types of infections is given in the article. Surgical procedures are the foundation of treatment of most intra-abdominal infections; antimicrobial agents active against aerobic gram-negative bacilli and anaerobes are important adjuncts.
本文描述了两种主要类型的腹腔内感染——腹膜炎和脓肿——的病因、病理生理学、临床表现及治疗方法。感染性腹膜炎是腹膜对微生物的急性反应；分为原发性（细菌来源不明）或继发性（通常涉及胃肠道中空结构穿孔，随后微生物释放）。由于液体转移和内毒素可能导致血容量不足和休克，腹膜炎可导致死亡。脓肿是与周围组织物理隔离的脓性液体聚集，是机体未能完全根除病原体后慢性炎症的结果。继发性腹腔内感染通常是多微生物感染，因为胃肠道中的微生物种类多样。细菌接种量的大小以及存在的菌种数量和类型对患者的预后有重大影响。腹膜炎患者通常表现为急性痛苦，伴有全腹痛和肠鸣音减弱。腹腔内脓肿患者的表现更为多样且不那么明显；可能存在疼痛和发热。这些感染的治疗需要及时进行手术干预、维持重要功能以及适当的抗菌治疗协同进行。手术用于阻止腹膜持续受到细菌污染、清除腹腔内的异物并引流脓性液体；这是治疗大多数类型腹腔内感染的基础。大多数患者需要积极的液体疗法以确保足够的血管内容量。一般来说，在获得培养结果之前，必须开始针对需氧菌和厌氧菌的抗菌覆盖。本文给出了针对特定类型感染的抗菌治疗方法。手术是大多数腹腔内感染治疗的基础；对需氧革兰氏阴性杆菌和厌氧菌有效的抗菌药物是重要的辅助治疗手段。
