Spontaneous bacterial peritonitis: Difference between revisions

Latest revision as of 18:08, 19 September 2024

Background

Primary infection of the ascitic fluid, diagnosed by ascites fluid with positive culture or with neutrophil count greater than 250

Microbiology

Escherichia coli (43%)
Klebsiella pneumoniae (11%)
Streptococcus pneumoniae (9%), particularly affecting people with HIV and prepubertal girls
Other streptococcal species (19%)
Enterobacteriaceae (4%)
Staphylococcus (3%)
Pseudomonas (1%)
Miscellaneous (10%)
- Aeromonas hydrophila, in Korea
- Peritoneal tuberculosis
- Dimorphic fungi

Pathophysiology

Intestinal bacterial overgrowth with increased intestinal permeability leads to translocation to intestinal lymph notes and bloodstream, which results in hematogenous seeding to ascitic fluid
Only occurs in portal hypertension, not in other causes of ascites

Risk Factors

Previous history of SBP
Upper GI bleed
Low sciatic protein
Child-Pugh class

Clinical Manifestations

Asymptomatic in 10%
Fever (70%)
Abdominal pain (60%)
Hepatic encephalopathy (50%)
Abdominal tenderness, usually without rigidity (50%)
Diarrhea (30%)
Ileus (30%)
Shock (20%)
Hypothermia (15%)

Variants

Culture-negative neutrocytic ascites: usually caused by difficult-to-treat organisms like tuberculosis, and non-infective sources
Monomicrobial non-neutrocytic bacterascites: early bacterial colonization
Polymicrobial bacterascites: usually from traumatic paracentesis

Prognosis and Complications

In-hospital mortality of about 33% in hospital
58% 6-month mortality

Investigations

Diagnostic paracentesis with ascitic fluid sent for cell count with differential and culture
- Neutrophil count < 250 rules it out
- Culture usually monomicrobial
Repeat paracentesis at 48h if ongoing concern

Management

Ceftriaxone 1-2g IV q24h + albumin 1.5 g/kg on day 1 and 1 g/kg on day 3

Prevention

Prophylaxis is indicated after even a single episode of SBP
- TMP-SMX SS or DS PO daily
- Norfloxacin 400 mg PO daily
- Ciprofloxacin 500 mg PO daily
- Doxycycline 100 mg PO daily is under investigations as an alternative1 (see abstract)
Possibly a role for primary prophylaxis

References

^ Ngoc Nguyen, Matthew Crotty, Edward A. Dominguez, Adil Habib, Hector E. Nazario, Zahid M. Vahora, Parvez S. Mantry, Jessiva Rago, Melanie Proffitt, Maisha N. Barnes, Ashwini Mehta, Mangesh R. Pagadala, Jeffrey S. Weinstein. Doxycycline for the prevention of spontaneous bacterial peritonitis. The Liver Meeting. 2023.

@@ Line 1: / Line 1: @@
+==Background==
-= Definition =
-* Primary infection of the ascitic fluid
+*Primary infection of the ascitic fluid, diagnosed by ascites fluid with positive culture or with neutrophil count greater than 250
+===Microbiology===
-= Pathophysiology =
+*''[[Escherichia coli]]'' (43%)
-* Intestinal bacterial overgrowth with increased intestinal permeability leads to translocation to intestinal lymph notes and bloodstream, which results in hematogenous seeding to ascitic fluid
+*''[[Klebsiella pneumoniae]]'' (11%)
-* Only occurs in portal hypertension, not in other causes of ascites
+*''[[Streptococcus pneumoniae]]'' (9%), particularly affecting people with [[HIV]] and prepubertal girls
+*Other streptococcal species (19%)
+*Enterobacteriaceae (4%)
+*''[[Staphylococcus]]'' (3%)
+*''[[Pseudomonas]]'' (1%)
+*Miscellaneous (10%)
+**''[[Aeromonas hydrophila]]'', in Korea
+**[[Peritoneal tuberculosis]]
+**[[Dimorphic fungi]]
+===Pathophysiology===
-= Bacteriology =
+*Intestinal bacterial overgrowth with increased intestinal permeability leads to translocation to intestinal lymph notes and bloodstream, which results in hematogenous seeding to ascitic fluid
-* ''Escherichia coli'' (43%)
+*Only occurs in portal hypertension, not in other causes of ascites
-* ''Klebsiella pneumoniae'' (11%)
-* ''Streptococcus pneumoniae'' (9%)
-* Other streptococcal species (19%)
-* Enterobacteriaceae (4%)
-* ''Staphylococcus'' (3%)
-* ''Pseudomonas'' (1%)
-* Miscellaneous (10%)
-** ''Aeromonas hydrophila'', in Korean
-= Risk Factors =
+===Risk Factors===
-* Previous history of SBP
+*Previous history of SBP
-* Upper GI bleed
+*[[Upper GI bleed]]
-* Low sciatic protein
+*Low sciatic protein
-* Child-Pugh class
+*Child-Pugh class
+==Clinical Manifestations==
-= Presentation =
-* Asymptomatic in 10%
+*Asymptomatic in 10%
-* Fever (70%)
+*Fever (70%)
-* Abdominal pain (60%)
+*Abdominal pain (60%)
-* Hepatic encephalopathy (50%)
+*Hepatic encephalopathy (50%)
-* Abdominal tenderness, usually without rigidity (50%)
+*Abdominal tenderness, usually without rigidity (50%)
-* Diarrhea (30%)
+*Diarrhea (30%)
-* Ileus (30%)
+*Ileus (30%)
-* Shock (20%)
+*Shock (20%)
-* Hypothermia (15%)
+*Hypothermia (15%)
+===Variants===
-= Investigations =
+*'''Culture-negative neutrocytic ascites:''' usually caused by difficult-to-treat organisms like tuberculosis, and non-infective sources
-* Labs
+*'''Monomicrobial non-neutrocytic bacterascites:''' early bacterial colonization
-** Ascitic fluid for cell count and culture
+*'''Polymicrobial bacterascites:''' usually from traumatic paracentesis
-*** Neutrophil count &lt; 250 rules it out
-*** Culture usually monomicrobial
-** Repeat paracentesis at 48h if ongoing concern
-* Imaging
-* Other
+===Prognosis and Complications===
-= Management =
+*In-hospital mortality of about 33% in hospital
-* Acute
+*58% 6-month mortality
-** Ceftriaxone 1-2g IV q24h
-* Chronic
-** Prophylaxis after a single episode
-*** Septra SS PO daily
-*** Norfloxacin
-* Some role for primary prophylaxis, I think?
+==Investigations==
-= Prognosis =
+*Diagnostic paracentesis with ascitic fluid sent for cell count with differential and culture
-* In-hospital mortality of about 33% in hospital
+**Neutrophil count &lt; 250 rules it out
-* 58% 6-month mortality
+**Culture usually monomicrobial
+*Repeat paracentesis at 48h if ongoing concern
+==Management==
+*[[Is treated by::Ceftriaxone]] 1-2g IV q24h + [[albumin]] 1.5 g/kg on day 1 and 1 g/kg on day 3
+==Prevention==
+*Prophylaxis is indicated after even a single episode of SBP
+**[[TMP-SMX]] SS or DS PO daily
+**[[Norfloxacin]] 400 mg PO daily
+**[[Ciprofloxacin]] 500 mg PO daily
+**[[Doxycycline]] 100 mg PO daily is under investigations as an alternative[[CiteRef::nguyen2023do]] (see [https://aasld.confex.com/aasld/2020/meetingapp.cgi/Paper/19190 abstract])
+*Possibly a role for primary prophylaxis
 [[Category:Intra-abdominal infections]]