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| __NOTOC__ | | __NOTOC__ |
| {{Spontaneous bacterial peritonitis}} | | {{Spontaneous bacterial peritonitis}} |
| {{CMG}}; {{AE}} {{ADI}} {{GRN}} {{SCh}} | | {{CMG}}; {{AE}} {{SCh}}{{AY}} |
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| ==Overview== | | ==Overview== |
| * Most episodes of [[spontaneous bacterial peritonitis]] (SBP) are thought to result from bacterial translocation from the gut.
| | No [[primary prevention]] described for SBP but early diagnosis and initiating [[Antibiotic|empiric antibiotic treatment]] is crucial for improving the prognosis. |
| * Given the risk of resistance and alteration of gut flora, this long-term antibiotic [[prophylaxis]] should be reserved for high-risk patients only.
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| * Identified risk factors for the development of SBP include:<ref name="pmid19475696">{{cite journal| author=Runyon BA, AASLD Practice Guidelines Committee| title=Management of adult patients with ascites due to cirrhosis: an update. | journal=Hepatology | year= 2009 | volume= 49 | issue= 6 | pages= 2087-107 | pmid=19475696 | doi=10.1002/hep.22853 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19475696 }} </ref>
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| ** Ascitic fluid [[total protein]] less than 1.0 g/dL,
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| ** [[Variceal bleeding|Variceal]] hemorrhage, and a
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| ** Prior episode of SBP.
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| * A variety of [[randomized controlled trials]] of prophylactic antibiotics in patients with ascites have shown a benefit for the prevention of development of SBP.
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| ==Primary prevention== | | ==Primary prevention== |
| * Cirrhotic patients with low protein ascites (less than 1.0 g/dL) and
| | No [[primary prevention]] described for SBP but early diagnosis and initiating [[Antibiotic|empiric antibiotic treatment]] is crucial for improving the prognosis. |
| * Either impaired renal or liver function and [[immunosuppression]] while the patient is at hospital are at increased risk of developing SBP.
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| * Although some controversy exists regarding the use of prophylactic antibiotics in patients who have never had SBP (primary prophylaxis), in one randomized trial, daily oral [[norfloxacin]] in patients with more advanced liver disease prevented the development of [[spontaneous bacterial peritonitis]] and [[hepatorenal syndrome]] and improved survival at 3 months when compared with those who received placebo.
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| * The [[AASLD guidelines classification scheme|AASLD]] guidelines suggest using long-term antibiotic prophylaxis in patients who have:
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| ** Ascitic fluid total protein less than 1.5 g/dL and at least one of the following:
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| ** Serum [[creatinine]] greater than or equal to 1.2 mg/dL,
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| ** [[Blood urea nitrogen]] greater than or equal to 25 mg/dL,
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| ** Serum [[sodium]] less than or equal to 130 mEq/L, or
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| ** Child-Turcotte-Pugh greater than or equal to 9 points (with [[bilirubin]] greater than or equal to 3 mg/dL).<ref name="pmid17854593">{{cite journal| author=Fernández J, Navasa M, Planas R, Montoliu S, Monfort D, Soriano G et al.| title=Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. | journal=Gastroenterology | year= 2007 | volume= 133 | issue= 3 | pages= 818-24 | pmid=17854593 | doi=10.1053/j.gastro.2007.06.065 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17854593 }} </ref><ref name="pmid9049193">{{cite journal| author=Novella M, Solà R, Soriano G, Andreu M, Gana J, Ortiz J et al.| title=Continuous versus inpatient prophylaxis of the first episode of spontaneous bacterial peritonitis with norfloxacin. | journal=Hepatology | year= 1997 | volume= 25 | issue= 3 | pages= 532-6 | pmid=9049193 | doi=10.1002/hep.510250306 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9049193 }} </ref>
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| ===Specific measures for high-risk cases===
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| {| border="2" cellpadding="4" cellspacing="0" style="margin: 1em 1em 1em 0; background: #f9f9f9; border: 1px #aaa solid; border-collapse: collapse;" width="75%"
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| ! '''Cirrhotic patients with gastrointestinal hemorrhage''' !! '''Non-bleeding cirrhotic patients with ascites'''
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| |-
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| * Between 25% and 65% of cirrhotic patients with [[gastrointestinal bleeding]] develop bacterial infection, including [[spontaneous bacterial peritonitis]].
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| * Antibiotic prophylaxis in this setting has been shown to decrease the risk of bacterial infections, the risk of re-bleeding, and overall [[mortality]].
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| * In one [[meta-analysis]] of five trials, antibiotic prophylaxis in cirrhotics with gastrointestinal bleeding demonstrated a 9% increase in survival.
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| * Indeed, the use of prophylactic antibiotics in this setting is thought to have contributed significantly to the reduced mortality in patients with variceal bleeding (from 43% to 15% over the past two decades).
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| * In this situation, the [[AASLD guidelines classification scheme|AASLD]] guidelines recommend using a 7-day course of intravenous [[ceftriaxone]] or twice daily oral [[norfloxacin]].
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| ** [[Ciprofloxacin]] 500mg PO BID X 7days<ref name="BernardGrangé1999">{{cite journal|last1=Bernard|first1=Brigitte|last2=Grangé|first2=Jean-Didier|last3=Khac|first3=Eric Nguyen|last4=Amiot|first4=Xavier|last5=Opolon|first5=Pierre|last6=Poynard|first6=Thierry|title=Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: A meta-analysis|journal=Hepatology|volume=29|issue=6|year=1999|pages=1655–1661|issn=02709139|doi=10.1002/hep.510290608}}</ref>
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| ** If the patient is NPO [[Ceftriaxone]] 1 g IV Q24H can be used
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| ** Switch to [[Ciprofloxacin]] 500 mg PO BID once bleeding is controlled
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| |valign=top|
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| * [[TMP/SMX]] 1 DS PO once daily or
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| * [[Ciprofloxacin]] 500mg PO daily if [[sulfa]] allergic.
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| * Intermittent dosing of antibiotics to prevent bacterial infections may be inferior to daily dosing (due to the development of bacterial resistance) and thus daily dosing should preferentially be used.<ref name="Fernández2002">{{cite journal|last1=Fernández|first1=J|title=Bacterial infections in cirrhosis: Epidemiological changes with invasive procedures and norfloxacin prophylaxis|journal=Hepatology|volume=35|issue=1|year=2002|pages=140–148|issn=02709139|doi=10.1053/jhep.2002.30082}}</ref><ref name="urlNational Guideline Clearinghouse | Management of adult patients with ascites due to cirrhosis: an update.">{{cite web |url=http://guideline.gov/content.aspx?id=14887&search=ascitis |title=National Guideline Clearinghouse | Management of adult patients with ascites due to cirrhosis: an update. |format= |work= |accessdate=}}</ref>
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| * Primary prophylaxis with [[norfloxacin]] has a great impact in the clinical course of patients with advanced [[cirrhosis]]. It reduces the incidence of spontaneous bacterial peritonitis, delays the development of [[hepatorenal syndrome]], and improves survival.<ref name="FernándezNavasa2007">{{cite journal|last1=Fernández|first1=Javier|last2=Navasa|first2=Miquel|last3=Planas|first3=Ramón|last4=Montoliu|first4=Silvia|last5=Monfort|first5=David|last6=Soriano|first6=German|last7=Vila|first7=Carmen|last8=Pardo|first8=Alberto|last9=Quintero|first9=Enrique|last10=Vargas|first10=Victor|last11=Such|first11=Jose|last12=Ginès|first12=Pere|last13=Arroyo|first13=Vicente|title=Primary Prophylaxis of Spontaneous Bacterial Peritonitis Delays Hepatorenal Syndrome and Improves Survival in Cirrhosis|journal=Gastroenterology|volume=133|issue=3|year=2007|pages=818–824|issn=00165085|doi=10.1053/j.gastro.2007.06.065}}</ref>
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| ==='''General long-term measures'''===
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| * Abstinence from [[alcohol]].
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| * Improvement in [[nutrition]] and general status of the patient.
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| * Aggressive treatment and eradication of localized [[infections]] before dissemination.
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| * Measures directed at reducing the risk of [[gastrointestinal bleeding]] or the development of [[ascites]], like surgical portacaval shunts or trans-jugular intrahepatic portasystemic stent-shunts, may help prevent SBP.
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| * [[Diuretic]] therapy decreases the AF volume and has been shown to significantly increase the AF opsonic activity, theoretically helping to prevent the development of SBP.<ref name="pmid9798013">{{cite journal| author=Such J, Runyon BA| title=Spontaneous bacterial peritonitis. | journal=Clin Infect Dis | year= 1998 | volume= 27 | issue= 4 | pages= 669-74; quiz 675-6 | pmid=9798013 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9798013 }} </ref>
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| ==References== | | ==References== |
| {{reflist|2}} | | {{reflist|2}} |
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| {{WH}}
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| {{WS}}
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| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| | [[Category:Emergency mdicine]] |
| | [[Category:Disease]] |
| | [[Category:Up-To-Date]] |
| [[Category:Infectious disease]] | | [[Category:Infectious disease]] |