Difference between revisions of "Spontaneous bacterial peritonitis"

Line 8: Line 8:
  
 
==Clinical Manifestations==
 
==Clinical Manifestations==
#Fever - 70%
+
*Fever - 70%
#Abdominal pain (diffuse) - 60%
+
*Abdominal pain (diffuse) - 60%
#Altered mental status - 55%  
+
*Altered mental status - 55%  
#~15% of patients have no signs/symptoms
+
*~15% of patients have no signs/symptoms
  
 
==Work-Up==
 
==Work-Up==
#Ascitic Fluid
+
*Ascitic Fluid
##Cell count, glucose, protein, gm stain, cx (10cc in blood cx bottle), LDH, alk phos
+
**Cell count, glucose, protein, gm stain, cx (10cc in blood cx bottle), LDH, alk phos
#Consider alternative Dx at the same time
+
*Consider alternative Dx at the same time
  
 
==Diagnosis==
 
==Diagnosis==
#Paracentesis results supporting a diagnosis of SBP:
+
*Paracentesis results supporting a diagnosis of SBP:
##Total WBC >500
+
**Total WBC >500
##Absolute neutrophil count > 250
+
**Absolute neutrophil count > 250
##Bacteria on gram stain (single type)
+
**Bacteria on gram stain (single type)
##SAAG > 1.1
+
**SAAG > 1.1
##Protein < 1, Glucose > 50 (otherwise concern for secondary bacterial peritonitis)
+
**Protein < 1, Glucose > 50 (otherwise concern for secondary bacterial peritonitis)
  
 
==Spontaneous versus secondary bacterial peritonitis==
 
==Spontaneous versus secondary bacterial peritonitis==
#Importance of distinction
+
*Importance of distinction
##Mortality of secondary bacterial peritonitis ~100% if tx is only abx without sx
+
**Mortality of secondary bacterial peritonitis ~100% if tx is only abx without sx
##Mortality of unnecessary sx in pt w/ SBP ~80%
+
**Mortality of unnecessary sx in pt w/ SBP ~80%
#Laboratory findings
+
*Laboratory findings
##Secondary bacterial peritonitis strongly suggested by:
+
**Secondary bacterial peritonitis strongly suggested by:
###Neutrocytic fluid (PMN ≥250) w/ two or more of the following:
+
***Neutrocytic fluid (PMN ≥250) w/ two or more of the following:
####Total protein concentration >1 g/dL (10 g/L)
+
****Total protein concentration >1 g/dL (10 g/L)
####Glucose concentration <50 mg/dL (2.8 mmol/L)  
+
****Glucose concentration <50 mg/dL (2.8 mmol/L)  
####LDH greater than upper limit of normal for serum
+
****LDH greater than upper limit of normal for serum
###Ascitic alk phos >240   
+
***Ascitic alk phos >240   
###Gram Stain
+
***Gram Stain
####Large numbers of different bacterial forms  
+
****Large numbers of different bacterial forms  
#Imaging
+
*Imaging
##If evidence of secondary bacterial peritonitis obtain abdominal imaging
+
**If evidence of secondary bacterial peritonitis obtain abdominal imaging
###If no evidence of free air or contrast extravasation then surgery is not indicated  
+
***If no evidence of free air or contrast extravasation then surgery is not indicated  
  
 
==Treatment==
 
==Treatment==
#Antibiotics
+
*Antibiotics
##SBP
+
**SBP
###Broad-spectrum covering enterobacter (63%), pneumococcus (15%), entercocci (10%)
+
***Broad-spectrum covering enterobacter (63%), pneumococcus (15%), entercocci (10%)
###Anaerobes causative agent <1%
+
***Anaerobes causative agent <1%
####3rd-generation cephalosporin is agent of choice:
+
****3rd-generation cephalosporin is agent of choice:
#####Cefotaxime 2g IV q8hr or [[Ceftriaxone]] 1-2g IV q12-24hr
+
*****Cefotaxime 2g IV q8hr or [[Ceftriaxone]] 1-2g IV q12-24hr
####If beta-lactam allergy consider ciprofloxacin 400mg IV q12hr
+
****If beta-lactam allergy consider ciprofloxacin 400mg IV q12hr
##Secondary bacterial peritonitis  
+
**Secondary bacterial peritonitis  
###3rd-generation cephalosporin + metronidazole  
+
***3rd-generation cephalosporin + metronidazole  
###Surgery
+
***Surgery
#Albumin
+
*Albumin
##Reduces renal failure and hospital mortality
+
**Reduces renal failure and hospital mortality
##1.5gm/kg at diagnosis; 1gm/kg on day 3
+
**1.5gm/kg at diagnosis; 1gm/kg on day 3
  
 
==Disposition==
 
==Disposition==
Line 65: Line 65:
 
[[Peritoneal dialysis-associated peritonitis]]
 
[[Peritoneal dialysis-associated peritonitis]]
  
==Source==
+
==References==
*Rosen's
 
*UpToDate
 
 
*Paracentesis. N Engl J Med 2006; 355
 
*Paracentesis. N Engl J Med 2006; 355
  
 
[[Category:GI]]
 
[[Category:GI]]

Revision as of 05:42, 30 May 2015

See Peritoneal dialysis-associated peritonitis for PD peritonitis

Background

  • Abreviation: SBP
  • Develops in large, clinically obvious ascites 2/2 cirrhosis
    • Normal flora translocate across the bowel wall into the peritoneum
  • 30% of ascitic pts will develop SBP in a given year
  • There is no platelet count or INR that is a contraindication to paracentesis

Clinical Manifestations

  • Fever - 70%
  • Abdominal pain (diffuse) - 60%
  • Altered mental status - 55%
  • ~15% of patients have no signs/symptoms

Work-Up

  • Ascitic Fluid
    • Cell count, glucose, protein, gm stain, cx (10cc in blood cx bottle), LDH, alk phos
  • Consider alternative Dx at the same time

Diagnosis

  • Paracentesis results supporting a diagnosis of SBP:
    • Total WBC >500
    • Absolute neutrophil count > 250
    • Bacteria on gram stain (single type)
    • SAAG > 1.1
    • Protein < 1, Glucose > 50 (otherwise concern for secondary bacterial peritonitis)

Spontaneous versus secondary bacterial peritonitis

  • 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

  • Antibiotics
    • SBP
      • Broad-spectrum covering enterobacter (63%), pneumococcus (15%), entercocci (10%)
      • Anaerobes causative agent <1%
        • 3rd-generation cephalosporin is agent of choice:
        • If beta-lactam allergy consider ciprofloxacin 400mg IV q12hr
    • Secondary bacterial peritonitis
      • 3rd-generation cephalosporin + metronidazole
      • Surgery
  • Albumin
    • Reduces renal failure and hospital mortality
    • 1.5gm/kg at diagnosis; 1gm/kg on day 3

Disposition

  • Can consider discharge w/ PO abx if pt has mild, uncomplicated disease and close f/u

See Also

Paracentesis Peritoneal dialysis-associated peritonitis

References

  • Paracentesis. N Engl J Med 2006; 355