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Key Features

  • Most peritonitis is an acute medical emergency

  • Primary bacterial peritonitis

    • Accounts for < 2% of childhood peritonitis

    • Most common causative organisms

      • Escherichia coli

      • Other enteric organisms

      • Hemolytic streptococci

      • Pneumococci

    • Occurs in patients with splenectomy, splenic dysfunction, or ascites (nephrotic syndrome, advanced liver disease, kwashiorkor)

    • Can also occur in infants with pyelonephritis or pneumonia

  • Secondary peritonitis

    • Much more common

    • Associated with peritoneal dialysis, abdominal trauma, or ruptured viscus

    • Organisms such as Staphylococcus epidermidis and Candida may cause secondary peritonitis in patients receiving peritoneal dialysis

    • Multiple enteric organisms may be isolated after abdominal injury, bowel perforation, or ruptured appendicitis

    • Intra-abdominal abscesses may form in pelvic, subhepatic, or subphrenic areas

  • In patients receiving peritoneal dialysis, peritonitis can be a chronic infection causing milder symptoms

Clinical Findings

  • Abdominal pain

  • Fever

  • Nausea, vomiting

  • Acidosis

  • Shock

  • Abdomen is tender, rigid, and distended, with involuntary guarding

  • Bowel sounds may be absent


  • Leukocyte count is high initially (> 20,000/μL) with a predominance of immature forms, and later it may fall to neutropenic levels, especially in primary peritonitis

  • Abdominal imaging can confirm the presence of ascites

  • Bacterial peritonitis should be suspected if paracentesis fluid

    • Contains > 500 leukocytes/μL or > 32 mg/dL of lactate

    • Has a pH < 7.34; or if the pH is over 0.1 pH unit < arterial blood pH

  • Diagnosis is made by Gram stain and culture, preferably of 5–10 mL of fluid for optimal yield

  • Blood culture is often positive in primary peritonitis


  • Antibiotic treatment and supportive therapy for dehydration, shock, and acidosis

  • Surgical treatment of the underlying cause of secondary peritonitis

  • Removal of infected peritoneal dialysis catheters in patients with secondary peritonitis is sometimes necessary and almost always required if Candida infection is present

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