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Spontaneous Bacterial Peritonitis

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Spontaneous Bacterial Peritonitis, Acute Spontaneous Bacterial Peritonitis

  • Definitions
  1. Primary Spontaneous Bacterial Peritonitis
    1. Spontaneous Bacterial Peritonitis in cirrhotic patients with Ascites
  • Epidemiology
  1. Incidence
    1. May represent as many as 25% of emergency department patients with Cirrhotic Ascites
    2. May represent as many as 30% of hospitalized patients with Cirrhotic Ascites
  • Causes
  1. Gram Negative Bacteria (e.g. Escherichia coli, Klebsiella)
  2. Gram Positive (e.g. Streptococcus species including Streptococcus Pneumoniae)
  3. Enterococcus faecalis
  • Symptoms
  1. Asymptomatic in 10 to 40% of cases
  2. Fever
  3. Abdominal Pain
  4. Increasing Ascites
  5. Nausea
  6. Vomiting
  • Signs
  1. Generalized abdominal tenderness
  2. Rebound Tenderness
  3. Fever
  4. Chills
  5. Tachycardia
  6. Tachypnea
  7. Shock state
  8. Acute liver decompensation (e.g. worsening encephalopathy, Renal Failure)
  • Precautions
  1. Symptoms and signs are variably present with 40% of patients asymptomatic
  2. Hospitalized patients carry an SBP risk as high as 30%
    1. Diagnostic Paracentesis for SBP is recommended in all hospitalized patients with significant Ascites
  • Labs
  1. Complete Blood Count
    1. Leukocytosis
  2. Ascitic Fluid by Paracentesis
    1. Ascitic Fluid Culture
      1. Obtain at least 20 ml fluid and split between 2 culture bottles (10 ml each), one aerobic and one anaerobic
      2. False Negative in 60% of cases
    2. Ascitic Fluid cell count and differential
      1. Total White Blood Cells (WBC ,Leukocytes) > 500/mm3
      2. Neutrophils (PMNs) > 250/mm3
        1. Test Sensitivity and Test Specificity: 93-94%
    3. Leukocyte esterase test strips positive
      1. Test Sensitivity: 93%
      2. Test Specificity: 100%
      3. Positive Predictive Value: 100%
      4. Negative Predictive Value: 98%
      5. Torun (2007) World J Gastroenterol 13(45):6027-30 [PubMed]
    4. Other markers that distinguish SBP from secondary peritonitis causes
      1. Peritoneal fluid Protein, Glucose, LDH, CEA, Alkaline Phosphatase
  • Imaging
  1. CT Abdomen and Pelvis
    1. Consider in cases where secondary peritonitis cause other than SBP is suspected
  1. Indications
    1. Ascitic fluid PMNs >250/mm3
    2. Signs of symptoms of SBP regardless of ascites PMN Count
      1. Repeat Paracentesis if negative ascitic fluid exam despite signs and symptoms
      2. Treat empirically with Antibiotics until confirmatory results
  2. Start immediately (high mortality rate)
  3. Duration: Mean treatment course of 5 days (up to 10-14 days)
  4. First line ParenteralAntibiotics
    1. Consider multidrug resistance to Cephalosporins
    2. Cefotaxime 2 grams every 8 hours
    3. Piperacillin-Tazobactam (Zosyn) 3.375 g IV every 6 hours
    4. Ceftriaxone 2 g IV every 24 hours
    5. Ertapanem 1 g IV every 24 hours
  5. Alternative Antibiotics if allergic to Penicillins, Cephalosporins and Carbapenems
    1. Ciprofloxacin 400 mg IV every 12 hours (if allergic )
  6. Alternative Antibiotics: Nosocomial source
    1. Meropenem 1 g IV every 8 hours AND Daptomycin 6 mg/kg IV every 24 hours
  • Management
  • Adjunctive Albumin
  1. Indications: SBP and one of the following lab findings
    1. Serum Creatinine >1 mg/dl
    2. Blood Urea Nitrogen >30 mg/dl
    3. Total Bilirubin >4 mg/dl
  2. Give albumin IV within 6 hours of diagnosis
    1. Dose 1: Albumin 1.5 gram/kg body weight initially
    2. Dose 2: Albumin 1 gram/kg on day 3
  3. Albumin efficacy in SBP
    1. Reduces in-hospital mortality and Renal Failure progression
    2. Jamtgaard (2016) Ann Emerg Med 67(4): 458-9 [PubMed]
    3. Long (2022) Am Fam Physician 106(4): 378A-B +PMID:36260890 [PubMed]
  • Prognosis
  1. Mortality approaches 20% per episode (as high as 40% in some studies)
  • Prevention
  1. Indications: Survivors of prior SBP episode
  2. Refer for Liver Transplantation
  3. Long-term prophylactic Antibiotics (see Hepatic Ascites for indications)
    1. Norfloxacin 400 mg once daily
    2. Ciprofloxacin 500 mg orally once daily OR
    3. Ciprofloxacin 750 mg orally once weekly
      1. Yim (2018) Am J Gastroenterol 113:1167 +PMID:29946179 [PubMed]
  • References
  1. (2019) Sanford Guide, accessed 4/9/2019
  2. Swaminathan and Pescatore in Herbert (2017) EM:Rap 17(11): 3
  3. Swencki (2015) Crit Dec Emerg Med 29(11):2-10
  4. Keating (2022) Am Fam Physician 105(4): 412-20 [PubMed]
  5. Runyon (2004) Hepatology 39:841-56 [PubMed]