Peritonitler ve İlişkili Hastalıklar: Sınıflandırma ve Yaklaşım
Özet
Peritonit, yüksek morbidite ve mortalite ile seyreden hayatı tehdit eden bir intraabdominal enfeksiyondur. Etiyolojik olarak primer (spontan bakteriyel peritonit), sekonder ve tersiyer olarak sınıflandırılır. Sekonder peritonit en sık görülen form olup genellikle polimikrobiyal enfeksiyonla ilişkilidir. Yaygın peritonitte mortalite %13–43 arasında değişmekte, tersiyer olgularda %50’nin üzerine çıkabilmektedir. Klinik tablo karın ağrısı, peritoneal irritasyon bulguları ve sistemik inflamatuar yanıt ile karakterizedir. Tanıda laboratuvar belirteçleri, yeni biyobelirteçler ve görüntüleme yöntemleri önemlidir; assitli hastalarda tanısal parasentez temel yaklaşımdır. Güncel kılavuzlara göre tedavi; hemodinamik resüsitasyon, kaynak kontrolü ve uygun antimikrobiyal tedaviyi içerir. Spontan bakteriyel peritonitte erken antibiyotik ve albümin desteği mortaliteyi azaltır. Ancak artan florokinolon direnci profilaksinin etkinliğini sınırlamaktadır. Periton diyalizi ilişkili peritonitte güncel kılavuzlar refrakter peritonit tanımı ve yeni sınıflandırmalar getirmiştir. Acil serviste erken tanı ve hızlı tedavi prognozu belirleyen temel faktörlerdir.
Peritonitis is a life-threatening intra-abdominal infection associated with high morbidity and mortality. Etiologically, it is classified as primary (spontaneous bacterial peritonitis), secondary, and tertiary. Secondary peritonitis is the most common form and is usually associated with polymicrobial infection. In diffuse peritonitis, mortality ranges between 13% and 43%, and may exceed 50% in tertiary cases. The clinical presentation is characterized by abdominal pain, signs of peritoneal irritation, and a systemic inflammatory response. Laboratory markers, novel biomarkers, and imaging modalities are important in diagnosis; diagnostic paracentesis is the main approach in patients with ascites. According to current guidelines, treatment includes hemodynamic resuscitation, source control, and appropriate antimicrobial therapy. In spontaneous bacterial peritonitis, early antibiotic therapy and albumin support reduce mortality. However, increasing fluoroquinolone resistance limits the effectiveness of prophylaxis. In peritoneal dialysis–associated peritonitis, current guidelines have introduced the definition of refractory peritonitis and new classifications. Early diagnosis and rapid treatment in the emergency department are the key determinants of prognosis.
Referanslar
Menichetti F, Sganga G. Definition and classification of intra-abdominal infections. Journal of Chemotherapy. 2009;21(Suppl 1):3–4. doi:10.1179/joc.2009.21.Supplement-1.3.
Ross JT, Matthay MA, Harris HW. Secondary peritonitis: principles of diagnosis and intervention. BMJ. 2018;361:k1407. doi:10.1136/bmj.k1407
Blot S, De Waele JJ. Critical issues in the clinical management of complicated intra-abdominal infections. Drugs. 2005;65(7):1611-1620. doi:10.2165/00003495-200565120-00002
De Waele JJ, Lipman J, Sakr Y, et al. Abdominal infections in the intensive care unit: characteristics, treatment and determinants of outcome. BMC Infectious Diseases. 2014 Jul 29;14:420. doi: 10.1186/1471-2334-14-420.
Tochie JN, Agbor NV, Frank Leonel TT, Mbonda A, Aji Abang D, Danwang C. Global epidemiology of acute generalised peritonitis: a protocol for a systematic review and meta-analysis. BMJ Open. 2020;10(1):e034326. doi:10.1136/bmjopen-2019-034326.
Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74(2):1014-1048. doi:10.1002/hep.31884.
European Association for the Study of the Liver. EASL clinical practice guidelines for the management of patients with decompensated cirrhosis. Journal of Hepatology. 2018;69(2):406-460. doi:10.1016/j.jhep.2018.03.024.
Li PK, Chow KM, Cho Y, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Peritoneal Dialysis International. 2022;42(2):110-153. doi:10.1177/08968608221080586.
Sartelli M, Abu-Zidan FM, Catena F, et al. Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study). World Journal of Emergency Surgery. 2015;10:61. doi:10.1186/s13017-015-0055-0.
Sartelli M, Chichom-Mefire A, Labricciosa FM, et al. The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines. World Journal of Emergency Surgery. 2017;12:29. doi:10.1186/s13017-017-0141-6.
Bonomo RA, Chow AW, Abrahamian FM, et al. 2024 clinical practice guideline update by the Infectious Diseases Society of America on complicated intra-abdominal infections: risk assessment in adults and children. Clinical Infectious Diseases. 2024 Aug 16;79(2):e51-e69. doi: 10.1093/cid/ciae312.
Huston JM, Barie PS, Dellinger EP, et al. The Surgical Infection Society guidelines on the management of intra-abdominal infection: 2024 update. Surgical Infections. 2024 Aug;25(6):419-435. doi: 10.1089/sur.2024.105.
Solomkin JS, Mazuski JE, Bradley JS, et al. 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. Clinical Infectious Diseases. 2010;50(2):133-64. doi: 10.1086/649554.
Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt). 2017 Jan;18(1):1-76. doi: 10.1089/sur.2016.261.
Szeto CC, Li PK, Johnson DW, et al. ISPD catheter-related infection recommendations: 2017 update. Peritoneal Dialysis International. 2017;37(2):141-154. doi:10.3747/pdi.2016.00120
Tamma PD, Aitken SL, Bonomo RA, et al. Infectious Diseases Society of America 2023 guidance on the treatment of antimicrobial resistant gram-negative infections. Clinical Infectious Diseases. 2023 Jul 18;77(Suppl 2):S28-S59. doi: 10.1093/cid/ciad428.
Fernández J, Piano S, Bartoletti M, et al. Management of bacterial and fungal infections in cirrhosis: the MDRO challenge. Journal of Hepatology. 2021;75(Suppl 1):S101-S117. doi:10.1016/j.jhep.2020.11.010.
Silvey S, Patel NR, Tsai SY, et al. Higher rate of spontaneous bacterial peritonitis recurrence with secondary spontaneous bacterial peritonitis prophylaxis compared with no prophylaxis in 2 national cohorts. Open Forum Infectious Diseases. 2024 May 27;11(6):ofae303. doi: 10.1093/ofid/ofae303.
Cai ZH, Fan CL, Zheng JF, et al. Procalcitonin and presepsin for detecting bacterial infection and spontaneous bacterial peritonitis in cirrhosis: a systematic review and meta-analysis. World Journal of Gastroenterology. 2019;25(11):1310-1322. doi:10.3748/wjg.v25.i11.1310.
Zhang J, Hu ZD, Song J, et al. Diagnostic value of presepsin for sepsis: a systematic review and meta-analysis. Medicine (Baltimore). 2015;94(47):e2158. doi:10.1097/MD.0000000000002158
Polilli E, Frattari A, Esposito JE, et al. Monocyte distribution width (MDW) as a biomarker for early sepsis detection: a systematic review and meta-analysis. International Journal of Molecular Sciences. 2023;24(5):4533. doi:10.3390/ijms24054533.
Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Medicine. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y.
Van Ruler O, Boermeester MA. Surgical treatment of secondary peritonitis: a continuing problem. Chirurg. 2017;88(Suppl 1):1-6. doi:10.1007/s00104-015-0121-x
Schein M, Marshall J. Source control: a guide to the management of surgical infections. 2nd ed. Berlin: Springer; 2021.
Sartelli M, Coccolini F, Kluger Y, et al. WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections. World Journal of Emergency Surgery. 2021;16(1):49. doi:10.1186/s13017-021-00387-8.
Montravers P, Dupont H, Leone M, et al. Guidelines for management of intra-abdominal infections. Anaesthesia Critical Care & Pain Medicine. 2015;34(2):117-130. doi:10.1016/j.accpm.2015.03.005
Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraperitoneal infection (STOP-IT). New England Journal of Medicine. 2015;372(21):1996-2005. doi:10.1056/NEJMoa1411162.
Referanslar
Menichetti F, Sganga G. Definition and classification of intra-abdominal infections. Journal of Chemotherapy. 2009;21(Suppl 1):3–4. doi:10.1179/joc.2009.21.Supplement-1.3.
Ross JT, Matthay MA, Harris HW. Secondary peritonitis: principles of diagnosis and intervention. BMJ. 2018;361:k1407. doi:10.1136/bmj.k1407
Blot S, De Waele JJ. Critical issues in the clinical management of complicated intra-abdominal infections. Drugs. 2005;65(7):1611-1620. doi:10.2165/00003495-200565120-00002
De Waele JJ, Lipman J, Sakr Y, et al. Abdominal infections in the intensive care unit: characteristics, treatment and determinants of outcome. BMC Infectious Diseases. 2014 Jul 29;14:420. doi: 10.1186/1471-2334-14-420.
Tochie JN, Agbor NV, Frank Leonel TT, Mbonda A, Aji Abang D, Danwang C. Global epidemiology of acute generalised peritonitis: a protocol for a systematic review and meta-analysis. BMJ Open. 2020;10(1):e034326. doi:10.1136/bmjopen-2019-034326.
Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74(2):1014-1048. doi:10.1002/hep.31884.
European Association for the Study of the Liver. EASL clinical practice guidelines for the management of patients with decompensated cirrhosis. Journal of Hepatology. 2018;69(2):406-460. doi:10.1016/j.jhep.2018.03.024.
Li PK, Chow KM, Cho Y, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Peritoneal Dialysis International. 2022;42(2):110-153. doi:10.1177/08968608221080586.
Sartelli M, Abu-Zidan FM, Catena F, et al. Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study). World Journal of Emergency Surgery. 2015;10:61. doi:10.1186/s13017-015-0055-0.
Sartelli M, Chichom-Mefire A, Labricciosa FM, et al. The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines. World Journal of Emergency Surgery. 2017;12:29. doi:10.1186/s13017-017-0141-6.
Bonomo RA, Chow AW, Abrahamian FM, et al. 2024 clinical practice guideline update by the Infectious Diseases Society of America on complicated intra-abdominal infections: risk assessment in adults and children. Clinical Infectious Diseases. 2024 Aug 16;79(2):e51-e69. doi: 10.1093/cid/ciae312.
Huston JM, Barie PS, Dellinger EP, et al. The Surgical Infection Society guidelines on the management of intra-abdominal infection: 2024 update. Surgical Infections. 2024 Aug;25(6):419-435. doi: 10.1089/sur.2024.105.
Solomkin JS, Mazuski JE, Bradley JS, et al. 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. Clinical Infectious Diseases. 2010;50(2):133-64. doi: 10.1086/649554.
Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt). 2017 Jan;18(1):1-76. doi: 10.1089/sur.2016.261.
Szeto CC, Li PK, Johnson DW, et al. ISPD catheter-related infection recommendations: 2017 update. Peritoneal Dialysis International. 2017;37(2):141-154. doi:10.3747/pdi.2016.00120
Tamma PD, Aitken SL, Bonomo RA, et al. Infectious Diseases Society of America 2023 guidance on the treatment of antimicrobial resistant gram-negative infections. Clinical Infectious Diseases. 2023 Jul 18;77(Suppl 2):S28-S59. doi: 10.1093/cid/ciad428.
Fernández J, Piano S, Bartoletti M, et al. Management of bacterial and fungal infections in cirrhosis: the MDRO challenge. Journal of Hepatology. 2021;75(Suppl 1):S101-S117. doi:10.1016/j.jhep.2020.11.010.
Silvey S, Patel NR, Tsai SY, et al. Higher rate of spontaneous bacterial peritonitis recurrence with secondary spontaneous bacterial peritonitis prophylaxis compared with no prophylaxis in 2 national cohorts. Open Forum Infectious Diseases. 2024 May 27;11(6):ofae303. doi: 10.1093/ofid/ofae303.
Cai ZH, Fan CL, Zheng JF, et al. Procalcitonin and presepsin for detecting bacterial infection and spontaneous bacterial peritonitis in cirrhosis: a systematic review and meta-analysis. World Journal of Gastroenterology. 2019;25(11):1310-1322. doi:10.3748/wjg.v25.i11.1310.
Zhang J, Hu ZD, Song J, et al. Diagnostic value of presepsin for sepsis: a systematic review and meta-analysis. Medicine (Baltimore). 2015;94(47):e2158. doi:10.1097/MD.0000000000002158
Polilli E, Frattari A, Esposito JE, et al. Monocyte distribution width (MDW) as a biomarker for early sepsis detection: a systematic review and meta-analysis. International Journal of Molecular Sciences. 2023;24(5):4533. doi:10.3390/ijms24054533.
Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Medicine. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y.
Van Ruler O, Boermeester MA. Surgical treatment of secondary peritonitis: a continuing problem. Chirurg. 2017;88(Suppl 1):1-6. doi:10.1007/s00104-015-0121-x
Schein M, Marshall J. Source control: a guide to the management of surgical infections. 2nd ed. Berlin: Springer; 2021.
Sartelli M, Coccolini F, Kluger Y, et al. WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections. World Journal of Emergency Surgery. 2021;16(1):49. doi:10.1186/s13017-021-00387-8.
Montravers P, Dupont H, Leone M, et al. Guidelines for management of intra-abdominal infections. Anaesthesia Critical Care & Pain Medicine. 2015;34(2):117-130. doi:10.1016/j.accpm.2015.03.005
Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraperitoneal infection (STOP-IT). New England Journal of Medicine. 2015;372(21):1996-2005. doi:10.1056/NEJMoa1411162.
