Spontaneous bacterial peritonitis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
- Spontaneous bacterial peritonitis (SBP) is a form of peritonitis that occurs in patients with advanced cirrhosis as a manifestation of severe derangement of hepatic function.
- And so, an episode of SBP has been proposed as an indication for liver transplantation in the absence of contraindications.
- It occurs in 10-30% of hospitalized patients with ascites.
- SBP has been studied extensively since its first description in 1964 which has lead to a greater understanding of the disease and reduction in the mortality from 80-90% to 30% or less in the past 10 years likely due to earlier detection and effective, nontoxic therapy.
- SBP has also been described to occur in various clinical settings, as in nephrotic syndrome or heart failure.
- SBP has been diagnosed with a positive bacterial culture for a single organism and an AF ( ascitic fluid) polymorphonuclear (PMN) cell count of >250mm3, in the absence of a surgically treatable intra-abdominal source of infection.
- More than 60% of SBP episodes are caused by enteric gram-negative organisms like Escherichia coli.
- Selective Intestinal Decontamination ( SID ) with fluorinated quinolones, to suppress the gram-negative intestinal flora has been known to reduce the incidence of SBP.
- SBP is a result of culmination of the inability of the gut to contain bacteria and failure of the immune system to eradicate the organisms once they have escaped.
- Predisposing factors for the AF infection in patients with Cirrhosis and ascites include:
- Severity of the liver disease.
- Serum total bilirubin level of >2.5 mg/dl.
- Total protein level <1 g/dl.
- Gasto-intestinal bleeding.
- Clinical signs and symptoms do not distinguish secondary from spontaneous peritonitis.
- AF analysis is helpful in differentiating SBP from secondary peritonitis which is a surgically treatable source of infection.
- The symptoms observed most frequently are Fever and abdominal pain.
- Because of this lack of specificity and sensitivity of clinical signs and symptoms, instances of unexplained deteri- oration in patients with cirrhosis should lead to a diagnostic paracentesis.
- Once diagnosed, patients with SBP should receive prompt empiric antibiotic treatment ( Cephalosporins) without waiting for the AF culture results because a delay in antibiotic treatment may result in a significant and potentially fatal deterioration in the clinical status of the patient.
- Prompt diagnosis and treatment maximize survival among patients with AF infections.
- Repeat paracenteses for follow-up of patients with SBP are considered to rule out secondary peritonitis if there is no clinical response to the treatment and the infection is polymicrobial.
- Those patients who survive an episode of SBP are at high risk of recurrence.
- Bacterascites represents the colonization of AF with bacteria without a neutrocytic response.
- Outcome depends on the clinical status of the patient:
- Patients with newly developed abdominal pain and/or temperature >100F are more prone to progress to SBP and therefore should receive empiric antibiotic treatment as stated for SBP
- Outcome depends on the clinical status of the patient:
- Currently, there are essentially no deaths as a result of SBP, provided it is detected and treated before the development of shock or renal failure, which are the most frequent complications of this disease.