Spontaneous Bacterial Peritonitis

DIAGNOSTICS

Paracentesis: 

 • Calculate absolute PMN count (total WBC x PMN %)

 • Correct PMN count for RBCs (subtract 1 PMN per 250 RBCs)

 • Obtain bacterial culture: ↑ yield by inoculating ascitic fluid in blood culture bottles

 • Distinguish from secondary peritonitis: protein > 1g/dL, glucose < 50mg/dL, LDH > ULN

Culture-negative neutrocytic ascites (CNNA) = PMN count > 250/mm3

 • Only -40% will have bacterial "culture-positive SBP"

 • Treat CNNA the same as culture-positive SBP due to similar outcomes/mortality

Non-neutrocytic bacterascites positive culture with PMN count less than 250/mm3:

 • Treat if other signs (fever, abdominal pain, etc). Otherwise repeat tap to recheck PMNs

Timing of paracentesis:

 • Recommended for all inpatients on non-elective hospital admission

 • Early (<12h) paracentesis = improved outcomes

1) Antibiotics

 • First-line: IV 3rd-gen cephalosporin, Consider pip-tazo or carbapenem if known high resistance rates or MDROs

 • Duration: 5-day course has been shown to be as good as 10 days

2) Albumin ↓ HRS and ↓ mortality (29% to 10%)

 • pay 1: 1.5 g/kg of 25% albumin

 • pay 3: lg/kg of 25% albumin

 • Caveats: Arbitrary dose, small study, low-risk pts may not derive much benefit

3) Other

 • ? Day 3 repeat paracentesis:

     AASLP: only if worsening symptoms, atypical presentation

     EASL: recommended for all

 • HOLD ß-blockers due to ↑ risk of HRS, mortality in SBP

 • PPIs = ↑ risk X Stop if no indication

 • Optimize volume control. Diuretics ↑ ascitic fluid opsonins

Prophylaxis:

 • Prior history of SBP: use ciprofloxacin or TMP-SMX

 • Active upper GI bleed: use IV CTX 

     - Can transition to fluoroquinolone to complete 7-day course

     - Any etiology (variceal or not)

     - ↓ rebleeding, infections/SBP, mortality

 • Ascitic fluid protein:

     < 1.5 g/dL and advanced liver disease (Child-Pugh > 9 and bilirubin 3) or renal insufficiency

     < 1.0 g/dL and hospitalized



- Dr. Hersh Shroff @HershShroff



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