Antibiotics are effective in preventing post-operative complications following infection of the peritoneum (peritonitis), but there is no evidence to support that one regimen is superior to another, and at the same time has less side effects.

Wong PF, Gilliam AD, Kumar S, Shenfine J, O'Dair GN, Leaper DJ

Published Online:

October 8, 2008

Patients with peritonitis originated from the gut will often require surgery. Antibiotics are useful in the treatment of the ongoing infection and for prevention of post-operative complications.
This review does not result in specific recommendations for any antibiotic regimen for the first line treatment of secondary peritonitis in adults, as all regimens showed equivocal efficacy. Other factors such as local guidelines and preferences, ease of administration, costs and availability must therefore be taken into consideration in deciding the antibiotic regimen of choice. More large scale trials are needed, and future trials should attempt to stratify patients and perform intention-to-treat analysis to allow better external validity.

Abstract (click to read)

Background:

Secondary peritonitis is associated with a high mortality rate and if not treated successfully leads to development of abscesses, severe sepsis and multi-organ failure. Source control and adjunctive antibiotics are the mainstay of treatment. However, no conclusive evidence suggest that one antibiotic regimen is better than any other but at the same time have a lower toxicity.

Objectives:

To ascertain the efficacy and adverse effects of different antibiotic regimens in treating intra-abdominal infections in adults. Outcomes were divided into primary (clinical success and effectiveness in reducing mortality) and secondary (microbiological success, preventing wound infection, intra-abdominal abscess, clinical sepsis, remote infection, superinfection, adverse reactions, duration of treatment required, effectiveness in reducing hospitalised stay, and time to defervescence).

Search strategy:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 4, 2004), MEDLINE (from 1966 to November 2004), EMBASE (from 1980 to November 2004) and Cochrane Colorectal Cancer Group specialised register SR-COLOCA.
Bibliographies of identified studies were screened for further relevant trials.

Selection criteria:

Randomised and quasi-randomised controlled trials comparing different antibiotic regimens in the treatment of secondary peritonitis in adults were selected. Trials reporting gynaecological or traumatic peritonitis were excluded from this review. Ambiguity regarding suitability of trials were discussed among the review team.

Data collection and analysis:

Six reviewers independently assessed trial quality and extracted data. Data collection was standardised using data collection form to ensure uniformity among reviewers. Statistical analyses were performed using the random effects model and the results expressed as odds ratio for dichotomous outcomes, or weight mean difference for continuous data with 95% confidence intervals.

Main results:

Fourty studies with 5094 patients met the inclusion criteria. Sixteen different comparative antibiotic regimens were reported. All antibiotics showed equivocal comparability in terms of clinical success. Mortality did not differ between the regimens. Despite the potential high toxicity profile of regimens using aminoglycosides, this was not demonstrated in this review. The reason for this could be the inherent bias within clinical trials in the form of patient selection and stringency in monitoring drug levels.

Authors' conclusions:

No specific recommendations can be made for the first line treatment of secondary peritonitis in adults with antibiotics, as all regimens showed equivocal efficacy. Other factors such as local guidelines and preferences, ease of administration, costs and availability must therefore be taken into consideration in deciding the antibiotic regimen of choice. Future trials should attempt to stratify patients and perform intention-to-treat analysis to allow better external validity.

This record should be cited as:

Wong PF, Gilliam AD, Kumar S, Shenfine J, O'Dair GN, Leaper DJ. Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD004539. DOI: 10.1002/14651858.CD004539.pub2

Assessed as up to date:

January 19, 2005

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Primary Review Group:

Colorectal Cancer Group

Health topics:

Gastroenterology > Non-neoplastic disease of the small & large bowel > Peritonitis

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Antibiotics are effective in preventing post-operative complications following infection of the peritoneum (peritonitis), but there is no evidence to support that one regimen is superior to another, and at the same time has less side effects.

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