Spontaneous Bacterial Peritonitis (SBP)

Clinical signs and laboratory findings in SBP

Ascetic fluid infection without a surgically treatable source
Ascites from portal hypertension should have a SAAG >1.1, but can be higher with acute infection
Total PMNs ≥ 250
+ culture from peritoneal fluid
In general only occurs in pts with ascites 2/2 advanced cirrhosis and significant ascites
Most common symptoms: fever, AMS, abd pain/tenderness (approx 10% have no symptoms)
Clinical features include leukocytosis, worsening renal insufficiency, acidosis
Alcoholic hepatitis can mimic SBP
Renal failure can develop in 30-40% of pts with SBP

Prophylaxis and treatment for SBP

Organisms are usually enteric: E. Coli, Klebsiella, however G+ cocci (strep pneumo,staph) can occur
Empiric tx with a 3rd gen cephalosporin (cefotaxime 2g IV Q8)
Intravenous albumin (1.5 g per kilogram of body weight at diagnosis and 1 g per kilogram 48 hours later) helps to prevent the hepatorenal syndrome and improves the probability of survival
Repeat paracentesis only indicated if lack of clinical response
risk factors for the development of SBP: ascitic fluid protein concentration <1.0 g/dL, variceal hemorrhage, and a prior episode of SBP
Patients who survive an episode of spontaneous bacterial peritonitis should receive long-term antibiotic prophylaxis with a flouroquinolone or trimethoprim/sulfamethoxazole (Bactrim, Septra)
Patients with gastrointestinal hemorrhage and cirrhosis should receive a flouroquinolone or trimethoprim/sulfamethoxazole twice daily for seven days (risk of bacterial gut translocation with acute bleed)

(Victoria Kelly MD, 9/24/10)