Evaluation and management of tertiary peritonitis.

Tertiary or recurrent peritonitis can occur after any operation for secondary bacterial peritonitis. The major risk factors for the development of tertiary peritonitis include malnutrition, a high Acute Physiology and Chronic Health Evaluation II score, the presence of organisms resistant to antimicrobial therapy, and organ system failure. Most patients with tertiary peritonitis will have fever and leukocytosis, even though other signs of infection may be absent. The management of tertiary peritonitis should include the provision of appropriate physiologic support, the administration of antimicrobial therapy, and operation or intervention to control the source of contamination and to decrease the bacterial load. Antibiotic-resistant organisms and bacteremia are present more commonly and mortality is greater in patients with tertiary peritonitis. Early recognition and effective intervention are critical to achieving a successful outcome.