Spontaneous Bacterial Peritonitis
DIAGNOSTICS
Paracentesis:
• Calculate absolute PMN count (total WBC x PMN %)
• Correct PMN count for RBCs (subtract 1 PMN per 250 RBCs)
• Obtain bacterial culture: ↑ yield by inoculating ascitic fluid in blood culture bottles
• Distinguish from secondary peritonitis: protein > 1g/dL, glucose < 50mg/dL, LDH > ULN
Culture-negative neutrocytic ascites (CNNA) = PMN count > 250/mm3
• Only -40% will have bacterial "culture-positive SBP"
• Treat CNNA the same as culture-positive SBP due to similar outcomes/mortality
Non-neutrocytic bacterascites positive culture with PMN count less than 250/mm3:
• Treat if other signs (fever, abdominal pain, etc). Otherwise repeat tap to recheck PMNs
Timing of paracentesis:
• Recommended for all inpatients on non-elective hospital admission
• Early (<12h) paracentesis = improved outcomes
1) Antibiotics
• First-line: IV 3rd-gen cephalosporin, Consider pip-tazo or carbapenem if known high resistance rates or MDROs
• Duration: 5-day course has been shown to be as good as 10 days
2) Albumin ↓ HRS and ↓ mortality (29% to 10%)
• pay 1: 1.5 g/kg of 25% albumin
• pay 3: lg/kg of 25% albumin
• Caveats: Arbitrary dose, small study, low-risk pts may not derive much benefit
3) Other
• ? Day 3 repeat paracentesis:
AASLP: only if worsening symptoms, atypical presentation
EASL: recommended for all
• HOLD ß-blockers due to ↑ risk of HRS, mortality in SBP
• PPIs = ↑ risk X Stop if no indication
• Optimize volume control. Diuretics ↑ ascitic fluid opsonins
Prophylaxis:
• Prior history of SBP: use ciprofloxacin or TMP-SMX
• Active upper GI bleed: use IV CTX
- Can transition to fluoroquinolone to complete 7-day course
- Any etiology (variceal or not)
- ↓ rebleeding, infections/SBP, mortality
• Ascitic fluid protein:
< 1.5 g/dL and advanced liver disease (Child-Pugh > 9 and bilirubin 3) or renal insufficiency
< 1.0 g/dL and hospitalized
- Dr. Hersh Shroff @HershShroff
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