Difference between revisions of "Spontaneous bacterial peritonitis"

(Differential Diagnosis)
(Diagnosis)
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==Diagnosis==
 
==Diagnosis==
 +
===Work-Up===
 +
*Ascitic Fluid
 +
**Cell count, glucose, protein, gm stain, culture (10cc in blood culture bottle), LDH, alk phos
 +
*Consider alternative diagnoses at the same time
 +
 +
===Fluid Analysis==
 
*Paracentesis results supporting a diagnosis of SBP:
 
*Paracentesis results supporting a diagnosis of SBP:
 
**Total WBC >500
 
**Total WBC >500
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**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)
 
===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
 
  
 
===Spontaneous versus secondary bacterial peritonitis===
 
===Spontaneous versus secondary bacterial peritonitis===

Revision as of 07:48, 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 Features

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

Differential Diagnosis

Diffuse Abdominal pain

Diagnosis

Work-Up

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

=Fluid Analysis

  • 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

References

  • Paracentesis. N Engl J Med 2006; 355