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