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primary or spontaneous bacterial peritonitis (SBP)

Etiology: 1) bacterial pathogens a) Escherichia coli b) Streptococcus pneumonia c) Streptococcus (other) 2) risk factors a) hepatic cirrhosis b) proton pump inhibitor [5] Epidemiology: - common in hospitalized patients with cirrhosis Pathology: - occurs only in patients with pre-existing ascites - patients with ascites related to portal hypertension are at highest risk Clinical manifestations: 1) abdominal pain & distension 2) fever 3) decreased bowel sounds 4) worsening of hepatic encephalopathy 5) more common with large-volume ascites 6) may occur in the absence of symptoms Laboratory: -> paracentesis a) cell count: > 250 neutrophils/uL b) positive culture 1] bedside innoculation of culture bottles with 10 mL of peritoneal fluid each [8] 2] SBP nearly always involves a single organism 3] if culture is polymicrobial, search for intra-abdominal focus of infection c) a & b confirms the diagnosis d) serum/peritoneal albumin > 1.1 & low peritoneal protein are risk factors Complications: - mortality 10-20% [3] Management: 1) hospitalization is indicated for patients with a) sepsis b) resistant or recurrent infections c) suspicion of organ perforation or abscess formation 2) empiric broad-spectrum antibiotics: a) cefotaxime or other 3rd generation cephalosporin + fluoroquinolone [2] c) assess response to therapy with repeat paracentesis 48 hours after initiation 1] cell count: neutrophils should decrease by 50% 2] cultures should be negative d) coverage for hospitalized patients should include: - gram negative bacteria including dual Pseudomonas aeruginona coverage - Staphylococcus aureus if cormorbid aspiration pneumonia suspected - vancomycin, levofloxacin, aztreonam - see Complications: above for cormorbid conditions 3) CAUTION: AVOID aminoglycosides a) may precipitate renal failure b) do not achieve adequate levels in ascitic fluid, c) are inactivated at acidic pH's 4) intravenous albumin (25%) a) indications: 1] serum creatinine > 1.0 mg/dL [3,13]; > 1.5 mg/dL [4] 2] serum urea nitrogen > 30 mg/dL [3] 3] advanced liver disease, serum bilirubin > 4 mg/dL 4] even if not volume-depleted b) 1.5 g/kg at diagnosis, then 1 g/kg on day 3 [3] c) may diminish risk of hepatorenal syndrome [3] - reduces risk of acute renal failure & death [12] 5) intravenous normal saline may worsen ascites 6) prognosis: a) mortality is 50-70% in hospitalized patients b) 1 year mortality is 60-80% in those that survive acute episode 7) prevention: a) long-term fluoroquinolone in patients with prolonged ascites b) norfloxacin 400 mg PO BID c) 750 mg ciprofloxacin weekly equivalent to daily norfloxacin 400 mg [9,11] d) high-risk patients with cirrhosis & ascites may not benefit from antibiotic prophylaxis to prevent spontaneous bacterial peritonitis [10]

Interactions

disease interactions

Related

paracentesis

General

bacterial peritonitis (BP)

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 275, 276, 312, 378
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 326
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015
  4. Talwalker JA & Kamath PS, Influence of recent advances in medical management on clinical outcomes of cirrhosis Mayo Clin Proc 80(11):1501, 2005 PMID: 16295030
  5. Goel GA et al. Increased rate of spontaneous bacterial peritonitis among cirrhotic patients receiving pharmacologic acid suppression. Clin Gastroenterol Hepatol 2012 Apr; 10:422 PMID: 22155557
  6. Runyon BA; AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009 Jun;49(6):2087-107 PMID: 19475696
  7. Runyon BA; AASLD. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013 Apr;57(4):1651-3 PMID: 23463403
  8. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018 Apr 10. PMID: 29653741 https://www.journal-of-hepatology.eu/article/S0168-8278(18)31966-4/fulltext
  9. Yim HJ, Suh SJ, Jung YK et al. Daily norfloxacin vs. weekly ciprofloxacin to prevent spontaneous bacterial peritonitis: A randomized controlled trial. Am J Gastroenterol 2018 Aug; 113:1167 PMID: 29946179 https://www.nature.com/articles/s41395-018-0168-7
  10. Komolafe O, Roberts D, Freemasn SC et al. Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis in people with liver cirrhosis: A network meta-analysis. Cochrane Database Syst Rev 2020 Jan 16; 1:CD013125 PMID: 31978256 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013125.pub2/full
  11. Biggins SW et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2021 Aug; 74:1014 PMID: 33942342 https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/hep.31884
  12. Nanchal R et al. Executive Summary: Guidelines for the management of adult acute and acute-on-chronic liver failure in the ICU: Neurology, peri-transplant medicine, infectious disease, and gastroenterology considerations. Crit Care Med 2023 May; 51:653. PMID: 37052435 https://journals.lww.com/ccmjournal/Fulltext/2023/05000/Executive_Summary__Guidelines_for_the_Management.10.aspx
  13. NEJM Knowledge+ - Sort P, Navasa M, Arroyo V 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 PMID: 10432325 Free article https://www.nejm.org/doi/pdf/10.1056/NEJM199908053410603