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| __NOTOC__ | | __NOTOC__ |
| {{Spontaneous bacterial peritonitis}} | | {{Spontaneous bacterial peritonitis}} |
| {{CMG}} ; {{AE}} {{ADI}} {{SCh}} | | {{CMG}} ; {{AE}}{{SCh}} {{AY}} |
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| ==Overview== | | ==Overview== |
| Despite remarkable knowledge and evidence about earlier detection, medical therapy, the average mortality rate of [[SBP]] remains elevated, ~ 30% ranging from < 5% in low-risk patients to ~ 90% in those at higher risk.In these patients, approximately half of all deaths occur after resolution of [[infection]] and are consequent to development of complications such as [[upper gastrointestinal bleeding]], [[renal dysfunction]], [[hepatic encephalopathy]] and [[paralytic ileus]].Among these complications, [[renal impairment]] is probably the strongest independent predictor of [[mortality]].The stronger predictors of poor outcome in [[SBP]] include the concurrent development of [[sepsis]] and subsequent [[multiple organ failure]] (MOF).
| | Early diagnosis and initiating treatment is the most important factor for improving the [[Survival rate|survival]] and avoiding the complications of SBP. The sooner the diagnosis, the better the outcome. |
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| ==Natural History , Complications and Prognosis== | | ==Natural history== |
| * Spontaneous bacterial peritonitis (SBP) is a potentially fatal yet reversible cause of deterioration in patients with decompensated [[cirrhosis]]. | | *SBP is treatable with [[antibiotics]] but early diagnosis and intiation of [[Antibiotic therapy|empiric antibiotic therapy]] is the most important factor for survival. |
| * SBP developing in the setting of [[ascites]] from causes other than [[cirrhosis]] is rare, but can occur in:
| | *In a study performed in 2006, Each hour of delay of administration of empiric antibiotics was associated with increased [[Mortality rate|mortality]] by 7.6% while administration of [[antibiotics]] at the first hour of [[hypotension]] increased overall survival to 79%.<ref name="pmid16625125">{{cite journal |vauthors=Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, Suppes R, Feinstein D, Zanotti S, Taiberg L, Gurka D, Kumar A, Cheang M |title=Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock |journal=Crit. Care Med. |volume=34 |issue=6 |pages=1589–96 |year=2006 |pmid=16625125 |doi=10.1097/01.CCM.0000217961.75225.E9 |url=}}</ref> |
| Cardiac ascites, nephrogenic ascites, ascites associated with [[fulminant hepatic failure]], malignant ascites, and alcoholic and viral [[hepatitis]].
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| * Untreated disease leads to complications and has a poor prognosis.
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| * Uncomplicated SBP is defined as spontaneous bacterial peritonitis in the absence of [[shock]], [[hemorrhage]], [[ileus]], severe [[renal failure]] and severe [[encephalopathy]].
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| ===Natural History=== | | ==Complications== |
| * Spontaneous bacterial peritonitis is a well-known complication of Cirrhotic ascites.
| | The physician should have a high index of suspicion to diagnose SBP early and start empiric antibiotic therapy. The earlier the stage of diagnosis, the better the survival. |
| * A longitudinal study conducted in 263 cirrhotic patients (HCV related in 127 cases and alcoholic in 136 cases) with a mean age of 6 I .2+/- I I .4 years), after the first ascites decompensation to evaluate the probability of SBP development, which describes the natural history of SBP and the results include the following:<ref name="CaneteErice2007">{{cite journal|last1=Canete|first1=N.|last2=Erice|first2=E.|last3=Bargallo|first3=A.|last4=Cirera|first4=I.|last5=Masnou|first5=H.|last6=Miquel|first6=M.|last7=Coll|first7=S.|last8=Gimenez|first8=M.D.|last9=Galeras|first9=J.A.|last10=Morillas|first10=R.M.|last11=Planas|first11=R.|last12=Sola|first12=R.|title=[219] NATURAL HISTORY OF SPONTANEOUS BACTERIAL PERITONITIS: A LONGITUDINAL STUDY IN 263 CIRRHOTIC PATIENTS AFTER THE FIRST ASCITES DECOMPENSATION|journal=Journal of Hepatology|volume=46|year=2007|pages=S90–S91|issn=01688278|doi=10.1016/S0168-8278(07)61817-0}}</ref>
| | ===Hypotension, hypothermia and shock:=== |
| ** Approximately 25% of cirrhotic patients developed SBP within the first 3 years after the first ascites decompensation, mainly if they have an ascitic fluid protein concentration below 10g/L. Although the SBP resolution was achieved in almost 90% ofcases, SBP-induced renal failure appeared in a third of the patients and it was associated with a short survival-rate. | | *With the progression of [[infection]], [[septicaemia]] ensues with its classic symptoms and signs. [[Septicaemia]] and [[shock]] are associated with very bad prognosis. |
| * SBP has evolved from a universally fatal disease to a reversible and even preventable cause of deterioration or death in a patient with advanced cirrhosis.<ref name="pmid15920324">{{cite journal| author=Sheer TA, Runyon BA| title=Spontaneous bacterial peritonitis. | journal=Dig Dis | year= 2005 | volume= 23 | issue= 1 | pages= 39-46 | pmid=15920324 | doi=10.1159/000084724 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15920324 }} </ref>
| | ===Altered mental status:=== |
| * Progression may be accelerated by the development of other complications such as (re)bleeding, hepatic ([[Hepatic encephalopathy]]) and renal impairment (refractory [[ascites]], [[hepato-renal syndrome]]), [[hepato-pulmonary syndrome]]. | | *[[Liver diseases|Hepatic decompensation]] in association with the progression of [[infection]] make [[altered mental status]] more likely to happen. [[Ammonia]] levels can be within normal limits or slightly elevated as [[Liver diseases|hepatic decompensation]] is not the only element leading to the [[altered mental status]]. |
| * SBP resolves with antibiotic therapy in approximately 90% of patients.<ref name="pmid19160207">{{cite journal| author=Chavez-Tapia NC, Soares-Weiser K, Brezis M, Leibovici L| title=Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. | journal=Cochrane Database Syst Rev | year= 2009 | volume= | issue= 1 | pages= CD002232 | pmid=19160207 | doi=10.1002/14651858.CD002232.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19160207 }} </ref> | | ===Paralytic ileus:=== |
| * Failure of antibiotic therapy is usually due to resistant bacteria or secondary bacterial peritonitis.
| | *[[Peritonitis|Peritoneal inflammation]] can be complicated with [[paralytic ileus]]. [[Paralytic ileus]] is a very poor prognostic sign with increased [[mortality rate]]. |
| | ===Diarrhea:=== |
| | *[[Diarrhea]] is common due to associated [[Bacterial overgrowth|intestinal bacterial overgrowth]].<ref name="pmid9210626">{{cite journal |vauthors=Guarner C, Runyon BA, Young S, Heck M, Sheikh MY |title=Intestinal bacterial overgrowth and bacterial translocation in cirrhotic rats with ascites |journal=J. Hepatol. |volume=26 |issue=6 |pages=1372–8 |year=1997 |pmid=9210626 |doi= |url=}}</ref> |
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| ===Complications=== | | ==Prognosis== |
| * [[Sepsis]]
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| * [[Encephalopathy]]
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| * [[Liver failure]]
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| * [[Renal failure]]
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| * Tense [[ascites]]
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| * [[Coma]]
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| * [[Death]]
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| ===Prognosis===
| | *[[Mortality rate|Mortality]] of SBP remains high. 1-year [[mortality rate]] is 30-90% <ref name="pmid25253362">{{cite journal |vauthors=Sundaram V, Manne V, Al-Osaimi AM |title=Ascites and spontaneous bacterial peritonitis: recommendations from two United States centers |journal=Saudi J Gastroenterol |volume=20 |issue=5 |pages=279–87 |year=2014 |pmid=25253362 |pmc=4196342 |doi=10.4103/1319-3767.141686 |url=}}</ref>, probably due to the advanced [[Liver diseases|liver disease]] present in the first place. |
| * The prognosis of SBP has improved dramatically since its first description. | | *Early admission and [[Cephalosporins|prophylactic cephalosporins]] might have a role in decreasing [[mortality rate]].<ref name="urlSpontaneous bacterial peritonis - ScienceDirect">{{cite web |url=http://www.sciencedirect.com/science/article/pii/0011502985900021?via%3Dihub |title=Spontaneous bacterial peritonis - ScienceDirect |format= |work= |accessdate=}}</ref> |
| * During the early 1970s, the mortality associated with hospitalization for SBP reached 80% to 90%. <ref name="pmid25091061">{{cite journal| author=Kim JJ, Tsukamoto MM, Mathur AK, Ghomri YM, Hou LA, Sheibani S et al.| title=Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis. | journal=Am J Gastroenterol | year= 2014 | volume= 109 | issue= 9 | pages= 1436-42 | pmid=25091061 | doi=10.1038/ajg.2014.212 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25091061 }} </ref>
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| * Since that time, the widespread use of paracentesis;
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| * Higher index of suspicion of infection; and the
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| * Clarification of diagnostic criteria, together with
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| * Use of better and safer antibiotics, has significantly improved the short-term prognosis of these patients.
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| * Currently, there are essentially no deaths as a result of this infection, provided it is detected and treated before the development of shock or renal failure.
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| * Unfortunately, the long-term prognosis remains extremely poor among survivors of an episode of SBP, a manifestation of severe impairment of liver function.
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| * Probabilities of survival of 1 and 2 years are in the range of 30% and 20%, respectively.
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| * Therefore, [[liver transplantation]] should be considered for patients who survive an episode of SBP in the absence of contraindications.<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><ref name="pmid15920324">{{cite journal| author=Sheer TA, Runyon BA| title=Spontaneous bacterial peritonitis. | journal=Dig Dis | year= 2005 | volume= 23 | issue= 1 | pages= 39-46 | pmid=15920324 | doi=10.1159/000084724 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15920324 }} </ref>
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| * Inpatient mortality has declined from 100% in the 1960s to 60–70% in the 1970s and 1980s to 30% or less in studies performed in the past 10 years. This is likely due to earlier detection and effective, nontoxic therapy.
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| * Approximately half of all deaths in patients with SBP occur after resolution of the infection and are from gastrointestinal hemorrhage or liver or renal failure.
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| * One study showed an overall mortality of 37.8% in patients admitted with SBP, but only 2.2% were directly attributable to infection
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| * The presence of renal insufficiency is the strongest independent prognostic indicator, but the presence of peripheral [[leukocytosis]], older age, higher [[Child-Pugh score]] <ref name="D'AmicoGarcia-Tsao2006">{{cite journal|last1=D'Amico|first1=Gennaro|last2=Garcia-Tsao|first2=Guadalupe|last3=Pagliaro|first3=Luigi|title=Natural history and prognostic indicators of survival in cirrhosis: A systematic review of 118 studies|journal=Journal of Hepatology|volume=44|issue=1|year=2006|pages=217–231|issn=01688278|doi=10.1016/j.jhep.2005.10.013}}</ref>, and the presence of an ileus have also been shown to predict inpatient mortality.<ref name="FolloLlovet1994">{{cite journal|last1=Follo|first1=Antonio|last2=Llovet|first2=Jose María|last3=Navasa|first3=Miquel|last4=Planas|first4=Ramón|last5=Forns|first5=Xavier|last6=Francitorra|first6=Anna|last7=Rimola|first7=Antoni|last8=Gassull|first8=Miguel Angel|last9=Arroyo|first9=Vicente|last10=Rodés|first10=Joan|title=Renal impairment after spontaneous bacterial peritonitis in cirrhosis: Incidence, clinical course, predictive factors and prognosis|journal=Hepatology|volume=20|issue=6|year=1994|pages=1495–1501|issn=02709139|doi=10.1002/hep.1840200619}}</ref>
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| * Patients with hospital versus community-acquired SBP also appear to have a higher mortality.
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| * Patients surviving an episode of SBP should be considered for liver transplantation if acceptable.
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| * The use of selective intestinal decontamination (SID) with [[norfloxacin]] in patients admitted to the hospital with low-protein ascites has also shown a reduction in the incidence of SBP from 22.5 to 0%
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| * [[Renal dysfunction]] is an important prognostic indicator followed by the [[Model for End-Stage Liver Disease]] [[(MELD) score]], which is a reliable measure of short-term mortality risk in patients with end-stage liver disease necessitating [[Liver transplantation]].<ref name="Kamath2001">{{cite journal|last1=Kamath|first1=P|title=A model to predict survival in patients with end-stage liver disease|journal=Hepatology|volume=33|issue=2|year=2001|pages=464–470|issn=02709139|doi=10.1053/jhep.2001.22172}}</ref> | |
| * With an increase of [[MELD score]] prognosis becomes worse. <ref name="pmid21145427">{{cite journal |author=Tandon P, Garcia-Tsao G |title=Renal dysfunction is the most important independent predictor of mortality in cirrhotic patients with spontaneous bacterial peritonitis |journal=Clin. Gastroenterol. Hepatol. |volume=9 |issue=3 |pages=260–5 |year=2011 |month=March |pmid=21145427 |doi=10.1016/j.cgh.2010.11.038 |url=}}</ref>
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| * The grave prognosis associated with a diagnosis of SBP in in-patients may not be applicable to outpatients with neutrocytic ascites.<ref name="pmid12668984">{{cite journal| author=Evans LT, Kim WR, Poterucha JJ, Kamath PS| title=Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites. | journal=Hepatology | year= 2003 | volume= 37 | issue= 4 | pages= 897-901 | pmid=12668984 | doi=10.1053/jhep.2003.50119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12668984 }} </ref>
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| * '''Predictors of mortality in SBP'''
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| **'''Modifiable factors''':
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| *** Timely diagnosis.
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| *** Effective first-line treatment.
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| **'''Bacterial factors'''
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| *** Culture-positivity (ascites/blood).
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| *** Bacterial load.
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| *** Multi-drug resistance to antibiotics.<ref name="pmid27099449">{{cite journal| author=Alexopoulou A, Vasilieva L, Agiasotelli D, Siranidi K, Pouriki S, Tsiriga A et al.| title=Extensively drug-resistant bacteria are an independent predictive factor of mortality in 130 patients with spontaneous bacterial peritonitis or spontaneous bacteremia. | journal=World J Gastroenterol | year= 2016 | volume= 22 | issue= 15 | pages= 4049-56 | pmid=27099449 | doi=10.3748/wjg.v22.i15.4049 | pmc=4823256 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27099449 }} </ref>
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| ** '''Host factors'''
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| *** Age.
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| *** Co-morbidity.
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| *** Site of acquisition of infection ( Community vs Nosocomial).
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| *** Severity of liver-dysfunction.
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| *** Genetic risk factors.
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| * The best predictor of survival is resolution of infection which is best influenced by effective first-line antibiotic therapy since other factors are not modifiable.<ref name="pmid16625125">{{cite journal| author=Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S et al.| title=Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. | journal=Crit Care Med | year= 2006 | volume= 34 | issue= 6 | pages= 1589-96 | pmid=16625125 | doi=10.1097/01.CCM.0000217961.75225.E9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16625125 }} </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]] |