Spontaneous bacterial peritonitis: Difference between revisions

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''See [[Peritoneal dialysis-associated peritonitis]] for PD peritonitis
==Background==
==Background==
*Develops in large, clinically obvious ascites 2/2 cirrhosis
*Develops in large, clinically obvious ascites secondary to cirrhosis
**Normal flora translocate across the bowel wall into the peritoneum
**Portal hypertension → bowel edema → normal flora translocates across bowel wall into the peritoneum
*30% of ascitic pts will develop SBP in a given year
*30% of ascitic patients will develop spontaneous bacterial peritonitis (SBP) in a given year
*There is no platelet count or INR that is a contraindication to paracentesis


==Clinical Manifestations==
===Causative Agents===
#Fever - 70%
*[[Enterobacter]] (63%)
#Abdominal pain (diffuse) - 60%
*[[Pneumococcus]] (15%)
#Altered mental status - 55%  
*[[Entercocci]] (10%)
#~15% of patients have no signs/symptoms
*[[Anaerobes]] (<1%)


==Work-Up==
==Clinical Features==
#Ascitic Fluid
*[[Fever]] (70%)
##Cell count, glucose, protein, gm stain, cx (10cc in blood cx bottle), LDH, alk phos
*[[Abdominal pain]] (diffuse) (60%)
*[[Altered mental status]] (55%)  
*~15% are asymptomatic


==Diagnosis==
==Differential Diagnosis==
#Paracentesis results supporting a diagnosis of SBP:
*[[Peritoneal dialysis-associated peritonitis]]
##Total WBC >1000
##Absolute neutrophil count > 250
##SAAG > 1.1
##Protein < 1, Glucose > 50 (otherwise concern for secondary bacterial peritonitis)


==Spontaneous versus secondary bacterial peritonitis==
{{Abdominal Pain DDX Diffuse}}
#Importance of distinction
##Mortality of secondary bacterial peritonitis ~100% if tx is only abx without sx
##Mortality of unnecessary sx in pt w/ SBP ~80%
#Laboratory findings
##Secondary bacterial peritonitis strongly suggested by:
###Neutrocytic fluid (PMN ≥250) w/ two or more of the following:
####Total protein concentration >1 g/dL (10 g/L)
####Glucose concentration <50 mg/dL (2.8 mmol/L)
####LDH greater than upper limit of normal for serum
###Ascitic alk phos >240 
###Gram Stain
####Large numbers of different bacterial forms
#Imaging
##If evidence of secondary bacterial peritonitis obtain abdominal imaging
###If no evidence of free air or contrast extravasation then surgery is not indicated


==Treatment==
==Evaluation==
#Antibiotics
''Consider alternative diagnoses at the same time''
##SBP
{{SBP workup}}
###Broad-spectrum covering gram + and gram -
{{Diagnosis of SBP}}
####3rd-generation cephalosporin is agent of choice:
{{Spontaneous versus secondary bacterial peritonitis}}
#####Cefotaxime 2g IV q8hr or Ceftriaxone 1-2g IV q12-24hr
####If beta-lactam allergy consider ciprofloxacin 400mg IV q12hr>
##2ndary bacterial peritonitis  
###3rd-generation cephalosporin + metronidazole
###Surgery
#Albumin
##Decreases incidence of renal failure
##1.5g/kg at time of diagnosis and 1g/kg on day 3


==Source==
==Management==
*Rosen's
===[[Antibiotics]]===
*UpToDate
*3rd-generation [[cephalosporin]]:
*Paracentesis. N Engl J Med 2006; 355
**[[Cefotaxime]] 2g IV q8hr or [[Ceftriaxone]] 1-2g IV q12-24hr
*If [[beta-lactam]] allergy, [[ciprofloxacin]] 400mg IV q12hr
*If peritoneal dialysis: [[vancomycin]] and [[cefepime]] <ref>Haines EJ, Oyama LC: Disorders of the Liver and Biliary Tract, in Walls RM, Hockberger RS, Gausche-Hill M, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 9. Philadelphia, Elsevier 2018, (Ch) 80:p 1083-1103.</ref>
 
===Albumin===
''Reduces renal failure and hospital mortality if given within 6 hours''<ref>Jamtgaard, et al. Does albumin infusion reduce renal impairment and mortality in patients with SBP. Annals of EM. April 2016. 67(4):458-458.</ref><ref>Sort, P et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999 Aug 5;341(6):403-9.</ref><ref>Xue, HP et al. Effect of albumin infusion on preventing the deterioration of renal function in patients with spontaneous bacterial peritonitis. Chinese Journal of Digestive Diseases, 2002 Jan 3: 32-34.</ref>
*Give for all or (larger effect) if creatinine >1mg/dL, BUN >30mg/dL, or T Bili >4mg/dL
*1.5gm/kg at within 6 hrs of diagnosis; 1gm/kg on day 3
 
==Disposition==
*Most admitted
**Can consider discharge with PO antibiotics if has mild, uncomplicated disease and close follow up
 
==See Also==
*[[Paracentesis]]
*[[Peritoneal dialysis-associated peritonitis]]
 
==References==
<references/>


[[Category:GI]]
[[Category:GI]]

Revision as of 06:11, 1 January 2021

See Peritoneal dialysis-associated peritonitis for PD peritonitis

Background

  • Develops in large, clinically obvious ascites secondary to cirrhosis
    • Portal hypertension → bowel edema → normal flora translocates across bowel wall into the peritoneum
  • 30% of ascitic patients will develop spontaneous bacterial peritonitis (SBP) in a given year

Causative Agents

Clinical Features

Differential Diagnosis

Diffuse Abdominal pain

Evaluation

Consider alternative diagnoses at the same time

SBP Work-Up of Ascitic Fluid via Paracentesis

  • Cell count with differential
  • Gram stain
  • Culture (10cc in blood culture bottle)
  • Glucose
  • Protein

Consider

  • Albumin and SERUM albumin
  • LDH and SERUM LDH at same time
  • Amylase

Specific circumstances

  • TB smear and culture
  • Cytology
  • TG
  • Billirubin

Diagnosis of SBP via Ascitic Fluid Analysis

Standard Evaluation

  • Paracentesis results supporting a diagnosis of SBP:
    • Absolute neutrophil count (PMNs) ≥250, pH <7.35, OR blood-ascites pH gradient >0.1[1]
    • Bacteria on gram stain (single type)
    • SAAG > 1.1
      • Diagnostic of portal hypertension with 97% accuracy[2]
      • SBP rarely develops in patients without portal hypertension
    • Protein < 1, Glucose > 50 (otherwise concern for secondary bacterial peritonitis)

For bloody tap, subtract 1 WBC for every 250 RBC[3]

If on peritoneal dialysis

See Peritoneal dialysis-associated peritonitis

  • Cell count >100/mm with >50% neutrophils most consistent with infection[4]

Spontaneous versus secondary bacterial peritonitis

  • Importance of distinction
    • Mortality of secondary bacterial peritonitis (eg. perforated appendicitis, cholecystitis) ~100% if treatment is only antibiotics without surgery
    • Mortality of unnecessary surgery in patients with SBP ~80%
  • Laboratory findings
    • Secondary bacterial peritonitis strongly suggested by:
      • Neutrocytic fluid (PMN ≥250) with two or more of the following:
        • Total protein concentration >1 g/dL (10 g/L)
        • Glucose concentration <50 mg/dL (2.8 mmol/L)
        • LDH greater than upper limit of normal for serum
      • Ascitic alk phos >240
      • Gram stain
        • Large numbers of different bacterial forms
  • Imaging
    • If evidence of secondary bacterial peritonitis obtain abdominal imaging
      • If no evidence of free air or contrast extravasation then surgery is not indicated

Management

Antibiotics

Albumin

Reduces renal failure and hospital mortality if given within 6 hours[6][7][8]

  • Give for all or (larger effect) if creatinine >1mg/dL, BUN >30mg/dL, or T Bili >4mg/dL
  • 1.5gm/kg at within 6 hrs of diagnosis; 1gm/kg on day 3

Disposition

  • Most admitted
    • Can consider discharge with PO antibiotics if has mild, uncomplicated disease and close follow up

See Also

References

  1. ↑ Wilkerson R, Sinert, R. The Use of Paracentesis in the Assessment of the Patient With Ascites. Ann Emerg Med 2009, 54(3): 465-68.
  2. ↑ Runyon BA, Montano AA, Akriviadis EA, et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992; 117:215.
  3. ↑ Hoefs JC "Increase in ascites white blood cell and protein concentrations during diuresis in patients with chronic liver disease."Hepatology. 1981;1(3):249. PMID 7286905
  4. ↑ ISPD GUIDELINES/RECOMMENDATIONS http://www.ispd.org/guidelines/articles/update/ispdperitonitis.pdf
  5. ↑ Haines EJ, Oyama LC: Disorders of the Liver and Biliary Tract, in Walls RM, Hockberger RS, Gausche-Hill M, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 9. Philadelphia, Elsevier 2018, (Ch) 80:p 1083-1103.
  6. ↑ Jamtgaard, et al. Does albumin infusion reduce renal impairment and mortality in patients with SBP. Annals of EM. April 2016. 67(4):458-458.
  7. ↑ Sort, P et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999 Aug 5;341(6):403-9.
  8. ↑ Xue, HP et al. Effect of albumin infusion on preventing the deterioration of renal function in patients with spontaneous bacterial peritonitis. Chinese Journal of Digestive Diseases, 2002 Jan 3: 32-34.
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