Spontaneous Bacterial Peritonitis

Question 1

Define spontaneous bacterial peritonitis.

Answer 1

An infection of the ascitic fluid that cannot be attributed to any intra-abdominal, ongoing inflammatory or surgically correctable condition. One of the most frequently encountered bacterial infections in patients with liver cirrhosis.

Question 2

What are the key diagnostic features in SBP?

Answer 2

• presence of risk factors
• abdominal pain/tenderness
• signs of ascites
• fever
• nausea/vomiting
• diarrhoea
• altered mental status
• GI bleeding

Others-
hypothermia, hypotension and tachycardia

Question 3

What are the risk factors for SBP?

Answer 3

• decompensated hepatic state (usually cirrhosis)
• low ascitic protein/ complement
• gastrointestinal bleeding
• endoscopic sclerotherapy for oesophageal varices
• ascites due to malignancy, renal insufficiency or congestive heart failure
• extra-intestinal infection
• invasive procedures

Question 4

What initial investigations should be done in SBP?

Answer 4

• FBC
• serum creatinine
• ascitic fluid appearance
• ascitic fluid absolute neutrophil count (ANC)
• ascitic fluid gram stain
• ascitic fluid culture
• blood cultures
• LFTs
• PT/INR

Question 5

Which other investigations should be considered?

Answer 5

• highly sensitive leukocyte esterase reagent strip testing of ascitic fluid (periscreen)
• bedside (standard urine) leukocyte esterase reagent strip testing of ascitic fluid
• ascitic fluid pH and blood arterial pH
• ascitic fluid protein, glucose, lactate dehydrogenase (LDH)
• ascitic fluid carcinoembryonic antigen (CEA)
• ascitic fluid alkaline phosphatase
• CT scan abdomen

EMERGING TESTS-

• ascitic fluid lactoferrin
• ascitic fluid PCR fot bacterial DNA
• serum procalcitonin

Question 6

What is the treatment plan for a complicated community acquired SBP?

Answer 6

1ST LINE
empirical IV abx
ADJUNCT
albumin
ADJUNCT
large-volume paracentesis

Question 7

What is the treatment plan for an uncomplicated community acquired SBP?

Answer 7

1ST LINE
empirical oral antibiotics
ADJUNCT
large-volume paracentesis

Question 8

What is the treatment for a nosocomial infection, septic shock or high risk for resistant species?

Answer 8

1ST LINE
empirical IV abx
ADJUNCT
vancomycin
ADJUNCT
albumin
ADJUNCT
broaden empirical regimen and assess further or switch to oral regimen
ADJUNCT
large-volume paracentesis

Question 9

What is given for primary or secondary prevention of SBP?

Answer 9

1ST LINE- antibiotic prophylaxis and beta blockers