Study of Organisms Cultured and their Drug Sensitivity in Peritoneal Fluid of Perforation Peritonitis Patient

Sredharan, M (2013) Study of Organisms Cultured and their Drug Sensitivity in Peritoneal Fluid of Perforation Peritonitis Patient. Masters thesis, Madras Medical College, Chennai.

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Abstract

INTRODUCTION: Perforative peritonitis is one of the most common surgical emergencies a surgeon would come across in his career. Among the general surgical conditions it also represents one of the most common causes of mortality. An internship of a surgeon would be termed incomplete had he not come across this ailment at least once. Perforative peritonitis encompasses a spectrum of disorders that affects the hollow viscera from stomach up to the rectum in its entire length. Even though a myriad of causes lead to the perforation of the bowel, the causes being unique in each part of the bowel, the clinical presentation is disquietingly similar. All these cases present as acute abdomen with tachycardia, abdomen guarding, rigidity, distension and absent bowel sounds. Patients usually are in septicemia with low blood pressure necessitating urgent resuscitation and immediate surgical intervention. Despite urgent resuscitation and immediate surgical intervention, the death rate among the patients of perforative peritonitis remains high. Septicemia and septic shock leading to sudden cardiac arrest remains the most common cause of death among the perforative peritonitis patients. One common practice among the leading as well as the budding surgeons, especially in the developing countries like India, is to use the highest antibiotic available in the hospital or institution in an attempt to reduce the mortality rate. Indiscriminate antibiotic usage is common especially in emergency settings. Though this practice saves some lives in the short term, it leads to evolution multi-drug resistant nosocomial infections in long run, leading to high mortality and cost burden on the patients as well as the state. The debate for using a proper empirical antibiotic continues because of the lack of direct comparative studies in large enough patient samples to make conclusions. Since the microbacterial spectrum that causes septicemia in perforative peritonitis remains fairly constant it is firmly believed among many surgeons that routine culture and sensitivity of peritoneal fluid wouldn’t yield any significant results. Another problem is that the results of the culture sensitivity wouldn’t benefit the patient since it takes days to get the results. Nevertheless routine culture sensitivity would simplify the antibiotic regime followed in the institution. This study is based on the concept that routine antibiotic sensitivity testing and usage of an empirical antibiotic in emergency setting can reduce health care cost by simplifying the antibiotic regime and improve mortality in long run by identifying emergence of drug resistant organisms. This study was conducted with the help of the patients admitted with hollow viscus perforation in Rajiv Gandhi Government General Hospital, Chennai between years 2010-2012. AIM OF THE STUDY: 1. To study the organisms cultured from the peritoneal fluid of patients presenting in the emergency department as acute abdomen and those who have ultrasound evidence of free fluid abdomen by bed side aspiration of the peritoneal fluid. 2. To study the drug sensitivity pattern of the organisms cultured in perforation peritonitis patients. 3. To correlate the organisms cultured to the site of perforation found intra-operatively. 4. To identify the most common drug the organisms are sensitive to. MATERIALS AND METHODS: This is an observational cross section study based on the microorganisms cultured from the peritoneal fluid and their drug sensitivity in patients presenting with free fluid abdomen due to perforative peritonitis in the emergency room. This study was conducted in the period 2011–2012, at the Department of General Surgery, Rajiv Gandhi Government General Hospital attached to Madras Medical College, Chennai. After obtaining consent from the ethical committee and informed consent from the patients presenting to the emergency room, patients with free fluid abdomen due to perforative peritonitis were clinically examined and bed side aspiration of peritoneal fluid done and fluid sent to the Microbiology department for culture and drug sensitivity. Only those patients who had an identifiable perforation site in laparotomy and with evidence of free fluid in Ultrasound abdomen were enrolled for this study. Study Design: This study is primarily an observational study and no attempt was made to alter the surgical treatment given to the patients by the treating surgeon at any point of time. No attempt was made to change the antibiotic regimen preferred by the treating surgeon. Data Collection: The following data about the patients are collected and analysed; • Name and sex, • Presenting complaints and its duration, • Presence or absence of fever, • Presence or absence of shock, • Presence or absence of air under diaphragm, • Site of perforation, • Nature of the aspirate, • Antibiotics administered, • Organisms cultured, • Drug sensitivity pattern of the organisms. Inclusion Criteria: 1. Patients with peritonitis due to hollow viscus perforation identifiable at laparotomy. 2. Perforative peritonitis patients with evidence of free fluid abdomen in Ultrasound. Exclusion Criteria: 1. Primary peritonitis patients. 2. Patients with traumatic bowel perforation. 3. Perforative peritonitis patients with no free fluid abdomen. 4. Peritonitis patients with no identifiable perforation site on laparotomy. METHODOLOGY: The bed side aspiration of the peritoneal fluid was done with the patient in supine position. The site of aspiration was painted with 5% povidone iodine solution. The skin was infiltrated with 2% lignocaine after sensitivity testing. Fluid aspiration was done with 18 gauge wide bore intra-venous cannula needle fitted to a 10ml syringe. 8 – 10ml of peritoneal fluid was collected and mixed with the carrier medium, the BACTEC medium in this case. CONCLUSION: Males are more commonly affected by perforative peritonitis than females in the ratio of 4:1. • Adults in the age group of 25 – 40 are most commonly afftected by perforative peritonitis. • More proximal the perforation is, lesser is the chance of isolation of organisms from the peritoneal fluid. • The probability of getting a positive peritoneal fluid culture increases with increase in duration of presenting symptoms. • A positive perforative peritoneal fluid culture correlates with the development of complications such as shock (P <0.0001). • A positive perforative peritoneal fluid culture can be used as a positive predicator for post-operative mortality of the patient from septicemia (P <0.0001). • The infection is almost always polymicrobial. Escherichia coli is the most common single organism isolated followed by Bacteroides fragilis. • Third generation broad spectrum cephalosporins with β lactamase inhibitor such as Cephaperazone – sulbactam, in combination with Metronidazole act as good empirical antibiotics. • Amikacin or gentamycin can be used as good adjuncts to increase efficacy, provided the renal parameters are within normal limits. • Use of Carbapenams can be restricted for complicated cases to avoid emergence of resistance.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Organisms Cultured ; Drug Sensitivity ; Peritoneal Fluid ; Perforation Peritonitis Patient.
Subjects: MEDICAL > General Surgery
Depositing User: Devi S
Date Deposited: 26 Mar 2018 14:53
Last Modified: 26 Mar 2018 14:53
URI: http://repository-tnmgrmu.ac.in/id/eprint/6593

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