Tertiary peritonitis represents the current limit of the surgical approach to severe intra-abdominal infection. Specific pathogens are cultured from the peritoneal cavity, although these appear to be more a symptom than the cause of critical illness. Therefore, the role of antimicrobial agents is debatable and currently reserved for infection with systemic toxicity and secondary sepsis. Short, narrow-spectrum courses are recommended with attention being paid to the individual pharmacokinetic profile of the drugs used. Lack of peritoneal inflammation with systemic anergy suggests immune paralysis. This anti-inflammatory state can have endogenous (primary massive insult, gut-associated sepsis, immune deficiency) or exogenous (repeated surgery, blood transfusions, immune suppressive drugs, malnutrition) origins. By development of immune monitoring assays, selective use of immune-modulating therapies could be beneficial. Pilot trials with immune stimulation show promising results. Finally, the endocrine stress response is essential for metabolic, cardiovascular and immunological homeostasis. Derangement of this response is likely in patients with prolonged stress such as tertiary peritonitis. Monitoring of endocrine function with substitution of cortisol when necessary could be beneficial in patients with tertiary peritonitis. The role of anabolic steroids like growth hormone is yet unclear.
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