Spontaneous bacterial peritonitis

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Background

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

Microbiology

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

Prevention

  • Prophylaxis is indicated after even a single episode of SBP
  • Possibly a role for primary prophylaxis

References

  1. ^  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.