Spontaneous bacterial peritonitis

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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

  1. Fever - 70%
  2. Abdominal pain (diffuse) - 60%
  3. Altered mental status - 55%
  4. ~15% of patients have no signs/symptoms

Work-Up

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

Diagnosis

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

Spontaneous versus secondary bacterial peritonitis

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

Treatment

  1. Antibiotics
    1. SBP
      1. Broad-spectrum covering enterobacter (63%), pneumococcus (15%), entercocci (10%)
      2. Anaerobes causative agent <1%
        1. 3rd-generation cephalosporin is agent of choice:
          1. Cefotaxime 2g IV q8hr or Ceftriaxone 1-2g IV q12-24hr
        2. If beta-lactam allergy consider ciprofloxacin 400mg IV q12hr
    2. Secondary bacterial peritonitis
      1. 3rd-generation cephalosporin + metronidazole
      2. Surgery
  2. Albumin
    1. Reduces renal failure and hospital mortality
    2. 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

Source

  • Rosen's
  • UpToDate
  • Paracentesis. N Engl J Med 2006; 355