Spontaneous Bacterial Peritonitis

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Spontaneous Bacterial Peritonitis

• Hrach Ike Kasaryan

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Introduction

• Definition- an ascitic fluid infection without an
  evident intraabdominal surgically-treatable
  source
• Any patient with ascites is essentially at risk
  for developing SBP however it primarily occurs in
  patients with ascites secondary to cirrhosis.

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Clinical Manifestations

• There is a very wide array of symptoms and signs
  which patients can present with for SBP
• The key is HIGH INDEX OF SUSPICION in patients
  with known ascites
• The most common symptom is fever, found in about
  80 of patients
• Abdominal pain in about 70, which can range from
  frank perotinitis to a mild pain
• An acute change in mental status can be the
  presenting symptom in some cases

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Clinical Manifestations

• Diarrhea may be the presentation in some

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Exam

• The exam can vary from a very rigid abdomen to a
  very soft nontender abdomen.
• Often times the rigid abdomen will not develop
  due to the amount of ascites present keeping the
  visceral and parietal layers of the abdomen
  separate

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Causative Agents

• The usual agents are those that are gut flora
• E. Coli 50
• Klebsiella 11
• S. Pneumonia 19
• Enterobacter 4
• Staph 3
• Psuedomonas 1
• Taken from a series of 519 patients with SBP
  diagnosis

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Diagnosis

• IN order to diagnose SBP, a diagnostic
  pericentesis must be done
• The purest definition for diagnosis is a ascitisc
  fluid PMN count is gt250 (500) and a postive
  ascitic fluid culture
• However not all patients with SBP read the
  diagnostic guidelines

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Diagnosis

• Ascites PMN count of gt500 is the best predictor
  of SBP even before cultures return
• A set of patients with SBP with a PMN gt250 will
  have a negative culture, in about 50 of cases.
  (may be due to poor culture technique). A.K.A.
  Culture-Negative Neutrocytic ascites

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Diagnosis

• Another subset will have a PMN count lt250 and a
  positive culture of a typical organism. 38 of
  these patient go on to develop SBP A.K.A.
  Monomicribial non-neutrocytic bacterascites
• Other helpful test in the diagnosis are
• lactate ascites lactate gt25 was 100 sensitive
  and specific in one retrospective analysis

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Treatment who?

• Those with PMN counts greater than 250 should all
  receive a course of therapy regardless of culture
  results.
• The more tricky situation is the Mono-microbial
  fluid with lt250 PMNs. Given that most go on to
  develop SBP, those patients should receive a
  course of therapy

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Treatment what?

• As mentioned previosly most cases are gut flora
  so naturally the abx that would cover those bugs
  should be used.
• Many studies have been done with varying results
  as to what is the optimal choice
• Currently a third generation cephalosporin is
  being recommended -gt cefotaxime
• Hepatology 1985 May-Jun5(3)457-62. Clin Infect
  Dis 1998 Oct27(4)669-74 quiz 675-6.  

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Treatment

• The hepatology study put cefotaxime head to head
  with ampicillin and found
• Higher cure rate (85 vs 56)
• Less ARF
• No superinfection
• Recommeded dose is 2g q 8
• Length of therapy was looked at in a trial, 5 vs
  10 days, and it was found to be equivalent, hence
  five days is currently recommended and re-asses
• Gastroenterology 1991 Jun100(6)1737-42.