primary or spontaneous bacterial peritonitis (SBP)
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Etiology
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
- abdominal pain & distention
- fever
- decreased bowel sounds
- worsening of hepatic encephalopathy
- more common with large-volume ascites
- may occur in the absence of symptoms
Laboratory
- paracentesis
- cell count: > 250 neutrophils/uL
- positive culture
- bedside innoculation of culture bottles with 10 mL of peritoneal fluid each[8]
- SBP nearly always involves a single organism
- if culture is polymicrobial, search for intra-abdominal focus of infection
- a & b confirms the diagnosis
- serum/peritoneal albumin > 1.1 & low peritoneal protein are risk factors
Complications
- mortality 10-20%[3]
Management
- hospitalization is indicated for patients with
- sepsis
- resistant or recurrent infections
- suspicion of organ perforation or abscess formation
- empiric broad-spectrum antibiotics:
- cefotaxime or other 3rd generation cephalosporin + fluoroquinolone[2]
- assess response to therapy with repeat paracentesis 48 hours after initiation
- cell count: neutrophils should decrease by 50%
- cultures should be negative
- coverage for hospitalized patients should include:
- gram negative bacteria including dual Pseudomonas aeruginona coverage
- Staphylococcus aureus if cormorbid aspiration pneumonia suspected
- see Complications: above for cormorbid conditions
- CAUTION: AVOID aminoglycosides
- may precipitate renal failure
- do not achieve adequate levels in ascitic fluid,
- are inactivated at acidic pH's
- intravenous albumin (25%)
- indications:
- serum creatinine > 1.0 mg/dL[3][13]; > 1.5 mg/dL[4]
- serum urea nitrogen > 30 mg/dL[3]
- advanced liver disease, serum bilirubin > 4 mg/dL
- even if not volume-depleted
- 1.5 g/kg at diagnosis, then 1 g/kg on day 3[3]
- may diminish risk of hepatorenal syndrome[3]
- reduces risk of acute renal failure & death[12]
- indications:
- intravenous normal saline may worsen ascites
- prognosis:
- mortality is 50-70% in hospitalized patients
- 1 year mortality is 60-80% in those that survive acute episode
- prevention:
- long-term fluoroquinolone in patients with prolonged ascites
- norfloxacin 400 mg PO BID
- 750 mg ciprofloxacin weekly equivalent to daily norfloxacin 400 mg[9][11]
- high-risk patients with cirrhosis & ascites may not benefit from antibiotic prophylaxis to prevent spontaneous bacterial peritonitis[10]
More general terms
Additional terms
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 275, 276, 312, 378
- ↑ 2.0 2.1 Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 326
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015
- ↑ 4.0 4.1 Talwalker JA & Kamath PS, Influence of recent advances in medical management on clinical outcomes of cirrhosis Mayo Clin Proc 80(11):1501, 2005 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16295030
- ↑ 5.0 5.1 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: https://www.ncbi.nlm.nih.gov/pubmed/22155557
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/19475696
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/23463403
- ↑ 8.0 8.1 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: https://www.ncbi.nlm.nih.gov/pubmed/29653741 https://www.journal-of-hepatology.eu/article/S0168-8278(18)31966-4/fulltext
- ↑ 9.0 9.1 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: https://www.ncbi.nlm.nih.gov/pubmed/29946179 https://www.nature.com/articles/s41395-018-0168-7
- ↑ 10.0 10.1 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: https://www.ncbi.nlm.nih.gov/pubmed/31978256 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013125.pub2/full
- ↑ 11.0 11.1 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: https://www.ncbi.nlm.nih.gov/pubmed/33942342 https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/hep.31884
- ↑ 12.0 12.1 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: https://www.ncbi.nlm.nih.gov/pubmed/37052435 https://journals.lww.com/ccmjournal/Fulltext/2023/05000/Executive_Summary__Guidelines_for_the_Management.10.aspx
- ↑ 13.0 13.1 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: https://www.ncbi.nlm.nih.gov/pubmed/10432325 Free article https://www.nejm.org/doi/pdf/10.1056/NEJM199908053410603