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Spontaneous bacterial peritonitis
Classification and external resources
ICD-9 567.23
eMedicine emerg/882

Spontaneous bacterial peritonitis (SBP) (a.k.a. primary peritonitis) is a form of peritonitis that occurs in patients with cirrhosis and children with nephrotic syndrome. It occurs in 10-30% of hospitalized patients with ascites, and can cause marked decompensation of the liver disease, with other complications and death occurring frequently.

Contents

Symptoms

Symptoms include fevers, chills, nausea, vomiting, abdominal tenderness and general malaise. Patients may complain of abdominal pain and worsening ascites. Hepatic encephalopathy may be the only manifestation of SBP; in the absence of a clear precipitant for the encephalopathy, all patients should undergo paracentesis, or sampling of the ascites fluid, in order to assess for SBP.

Diagnosis

Diagnosis necessitates paracentesis (needle drainage of the ascitic fluid) and laboratory confirmation of ascitic neutrophils > 250/mm³.

Treatment

Antibiotics

After confirmation of SBP, patients need hospital admission for intravenous antibiotics (most often cefotaxime 2g IV Q8-12H for at least 5 days or ceftriaxone 2g IV Q24H). They will often also receive intravenous albumin. A repeat paracentesis in 48 hours is sometimes performed to ensure control of infection. Once patients have recovered from SBP, they require regular prophylactic antibiotics (e.g. Septra DS 1 tab 5 times/week, Ciprofloxacin 750mg PO Q1W, norfloxacin 400mg Q24H) as long as they still have ascites.

Intravenous albumin

A randomized controlled trial found that intravenous albumin on the day of admission and on hospital day 3 can reduce renal impairment.[1]

Prevention/screening

All cirrhotic patients might benefit from antibiotics if:

  • Ascitic fluid protein <1.0 g/dL[2]. Patients with fluid protein <15 g/L and either Child-Pugh score of at least 9 or impaired renal function may also benefit.[3]
  • Previous SBP[4]

Cirrhotic patients admitted to the hospital should receive antibiotics if:

References

  1. ^ Sort P, Navasa M, Arroyo V, et al. (1999). "Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis". N. Engl. J. Med. 341 (6): 403–9. doi:10.1056/NEJM199908053410603. PMID 10432325.  
  2. ^ Runyon BA (1986). "Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis". Gastroenterology 91 (6): 1343–6. PMID 3770358.  
  3. ^ Fernández J, Navasa M, Planas R, et al. (2007). "Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis". Gastroenterology 133 (3): 818–24. doi:10.1053/j.gastro.2007.06.065. PMID 17854593.  
  4. ^ Grangé JD, Roulot D, Pelletier G, et al. (1998). "Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites: a double-blind randomized trial". J. Hepatol. 29 (3): 430–6. doi:10.1016/S0168-8278(98)80061-5. PMID 9764990.  
  5. ^ Soares-Weiser K, Brezis M, Tur-Kaspa R, Leibovici L (2002). "Antibiotic prophylaxis for cirrhotic patients with gastrointestinal bleeding". Cochrane database of systematic reviews (Online) (2): CD002907. doi:10.1002/14651858.CD002907. PMID 12076458.  







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