title: Management of secondary peritonitis.
abstract: OBJECTIVE
  The authors review current definition, classification, scoring, microbiology, inflammatory response, and goals of management of secondary peritonitis.
  
  
  BACKGROUND
  Despite improved diagnostic modalities, potent antibiotics, modern intensive care, and aggressive surgical treatment, up to one third of patients still die of severe secondary peritonitis. Against the background of current understanding of the local and systemic inflammatory response associated with peritonitis, there is growing controversy concerning the optimal antibiotic and operative therapy, intensified by lack of properly conducted randomized studies. In this overview the authors attempt to outline controversies, suggest a practical clinical approach, and highlight issues necessitating further research.
  
  
  METHODS
  The authors review the literature and report their experience.
  
  
  RESULTS
  The emerging concepts concerning antibiotic treatment suggest that less-in terms of the number of drugs and the duration of treatment-is better. The classical single operation for peritonitis, which obliterates the source of infection and purges the peritoneal cavity, may be inadequate for severe forms of peritonitis; for the latter, more aggressive surgical techniques are necessary to decompress increased intra-abdominal pressure and prevent or treat persistent and recurrent infection. The widespread acceptance of the more aggressive and demanding surgical methods has been hampered by the lack of randomized trials and reportedly high associated morbidity rates.
  
  
  CONCLUSIONS
  Sepsis represents the host's systemic inflammatory response to bacterial peritonitis. To improve results, both the initiator and the biologic consequences of the peritoneal infective-inflammatory process should be addressed. The initiator may be better controlled in severe forms of peritonitis by aggressive surgical methods, whereas the search for methods to abort its systemic consequences is continuing.
authors.affiliation: Department of Surgery, Medical College of Wisconsin, Milwaukee 53226, USA.
authors.forename: D H
authors.initials: DH
authors.lastname: Wittmann
authors.forename: M
authors.initials: M
authors.lastname: Schein
authors.forename: R E
authors.initials: RE
authors.lastname: Condon
mesh_terms: D000005:Abdomen / Q000601:surgery; D000038:Abscess / Q000601:surgery; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D006801:Humans; D010538:Peritonitis / Q000145:classification / Q000209:etiology / Q000382:microbiology / Q000628:therapy*
chemical_list: D000900:Anti-Bacterial Agents