Important measures include fluid resuscitation, antibiotic therapy, and in most cases surgery.

Fluid resuscitation entails administration of fluids and monitoring of fluid status. In the critically ill, resuscitative measures must be directed by invasive monitoring techniques such as the pulmonary artery catheter. Controversy over the use of colloid versus crystalloid for resuscitation of the septic hypovolemic patient remains unanswered. Crystalloid resuscitation, which requires much larger volumes, appears to be as effective as colloid. Because crystalloid is readily available and inexpensive, it may well be the solution of choice. The use of starch for isovolemic hemodilution in these conditions is the subject of ongoing investigation.

Antibiotic therapy should be initiated as soon as the clinical diagnosis of intra-abdominal sepsis is made. The choice of agent should be based on the suspected offending organism and on the ability of the antibiotics to achieve adequate levels at the site where needed. Intra-abdominal sepsis is almost always polymicrobial. Gram-negative enteric bacteria (e.g. E. coli) and anaerobic bacteria (e.g. B. fragilis) are most commonly found. Most clinicians agree that antibiotic therapy directed against these bacteria is the mainstay of treatment of intra-abdominal sepsis. We use a combination of cefuroxime, gentamicin, and metronidazole as the initial treatment of diffuse peritonitis. When cultures are available, antibiotic treatment is adjusted if necessary. In principle, a 5-day antibiotic course is given. If the patient is compromised with respect to susceptibility to opportunistic pathogens, an antibiotic that is effective against enterococci should be included in the regimen. Moreover, enterococcal bacteremia or the recovery of enterococci from a residual or recurrent intra-abdominal infection is an indication for coverage by the appropriate antibiotic.

In some critically ill patients with evidence of sepsis and multiple organ dysfunction, a so-called tertiary peritonitis develops. This type of peritonitis is persistent and diffuse, responds poorly to drainage, and presents a difficult problem with respect to antibiotic management. The usual empirical therapy is no longer valid, as the infections are caused by Staphylococcus epidermidis, Pseudomonas aeruginosa, Candida species, and enterococci, rather than by E. coli and B. fragilis. Microbial cure is unusual in these situations despite efficacy of appropriate antibiotics for such infections. This failure in cure is probably caused by general failure of host defense mechanisms.

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