Patients with evidence of secondary peritonitis should be referred immediately for surgical evaluation. Prompt surgery is the mainstay of treatment for patients with secondary peritonitis to control the source of contamination and to remove necrotic tissue, blood, or intestinal contents from the peritoneal cavity. Medical management consists of antimicrobial therapy and physiologic support of the patient. The mortality rate of secondary peritonitis approaches 100% if treatment does not include surgical intervention.The choice of antimicrobial agents is generally made empirically, based on the likely pathogens. Although no clinical trials have demonstrated the superiority of one antimicrobial regimen over the other/it is known that both anaerobes and gram-negative aerobes should be covered. Combination antimicrobial therapy has traditionally been used, although single broad-spectrum agents, including beta-lactam/beta-lactamase inhibitor combinations and the carbapenems, are alternatives. Recommendations for empiric therapy depend on the severity of illness and whether the infection was acquired in a community or hospital setting. The duration of antimicrobial therapy after surgery is usually 5 to 7 days, depending on the severity of the infection, clinical response, and normalization of the white blood cell count.The role of enterococci in secondary peritonitis is not clearly defined, as most cases of secondary peritonitis are cured with regimens that do not have activity against enterococcus. However, regimens that include specific enterococcal coverage are recommended if these organisms grow in a pure culture from an intra-abdominal source of infection or from the blood.*93/348/5*
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