II. 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

IV. Symptoms

  1. Asymptomatic in 40% of cases
  2. Fever
  3. Abdominal Pain
  4. Increasing Ascites
  5. Nausea
  6. Vomiting

V. 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)

VI. Precautions

  1. Symptoms and signs are variably present with 40% of patients asymptomatic

VII. Labs

  1. Complete Blood Count
    1. Leukocytosis
  2. Ascitic Fluid by Paracentesis
    1. Ascitic Fluid Culture
      1. False negative in 60% of cases
    2. Neutrophils (PMNs) > 250/mm3
      1. Test Sensitivity and Test Specificity: 93-94%
    3. Leukocytes > 500/mm3
    4. Leukocyte esterase test strips positive
    5. Other markers that distinguish SBP from secondary peritonitis causes
      1. Peritoneal fluid protein, Glucose, LDH, CEA, Alkaline Phosphatase

VIII. Imaging

  1. CT Abdomen and Pelvis
    1. Consider in cases where secondary peritonitis cause other than SBP is suspected

IX. Management: Empiric antibiotics

  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: 10-14 days
  4. Parenteral antibiotics
    1. Cefotaxime 2 grams every 8 hours
    2. Nosocomial source of infection may require broadening of antibiotic coverage
  5. Oral antibiotics
    1. Oral agents
      1. Ofloxacin 400 mg orally twice daily
      2. Amoxicillin-Clavulanate (Augmentin)
    2. Indications for oral therapy
      1. Tolerating oral (no Vomiting)
      2. No shock or severe Hepatic Encephalopathy
      3. Serum Creatinine <3 mg/dl
    3. Spanish Study (n=123)
      1. Stable patients with SBP treated for 7 days
      2. Cipro PO as effective as Cefotaxime IV (84%)
      3. Navasa (1996) Gastroenterology 111:1011-7 [PubMed]

X. 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]

XI. Prognosis

  1. Mortality approaches 20% per episode (as high as 40% in some studies)

XII. Prevention

  1. Indications: Survivors of prior SBP episode
  2. Refer for liver transplantation
  3. Long-term prophylactic antibiotics
    1. Norfloxacin
    2. Trimethoprim-sulfamethoxazole (Septra)

XIII. References

  1. Swaminathan and Pescatore in Herbert (2017) EM:Rap 17(11): 3
  2. Swencki (2015) Crit Dec Emerg Med 29(11):2-10
  3. Runyon (2004) Hepatology 39:841-56 [PubMed]

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Ontology: Primary bacterial peritonitis (C0275551)

Concepts Disease or Syndrome (T047)
ICD9 567.23
ICD10 K65.2
SnomedCT 11836002
English Spont bacterial peritonitis, SBP - Spont bacter peritonitis, Primary bacterial peritonitis, Spontan bact peritonitis, primary bacterial peritonitis, bacterial peritonitis spontaneous, Spontaneous bacterial peritonitis, SBP - Spontaneous bacterial peritonitis, Primary bacterial peritonitis (disorder)
Dutch spontane bacteriële peritonitis
French Péritonite bactérienne spontanée
German spontane bakterielle Peritonitis
Italian Peritonite batterica spontanea
Portuguese Peritonite bacteriana espontânea
Spanish Peritonitis espontánea bacteriana, peritonitis bacteriana espontánea, peritonitis bacteriana primaria (trastorno), peritonitis bacteriana primaria
Japanese 特発性細菌性腹膜炎, トクハツセイサイキンセイフクマクエン
Czech Spontánní bakteriální peritonitida
Hungarian spontán bacterialis peritonitis