Spontaneous Bacterial Peritonitis (SBP)

Question 1

what is Spontaneous Bacterial Peritonitis (SBP)?

Answer 1

Ascitic fluid infection with no evidence of surgically treatable source (hence, “spontaneous”)

Question 2

Vast majority of patients that have Spontaneous Bacterial Peritonitis (SBP) have what?

Answer 2

advanced cirrhosis

Question 3

what are some risk factors (often associated with liver disease) for infection if SBP?
(5)

Answer 3

1. Ascitic fluid total protein <1 g/dL. –> Low protein count
2. Past episodes of SBP
3. Serum total bilirubin >2.5 mg/dL –>High bilirubin
4. Variceal hemorrhage
5. PPI use –>changes pH and makes it easier for certain organisms to outperform others

Question 4

SBP: Pathogenesis

Answer 4

• Liver disease (cirrhosis) predisposes to bacterial overgrowth and increased intestinal permeability
• Bacteria within gut can traverse intestinal wall and colonize mesenteric lymph nodes (translocation)
• Bacterascites can occur with lymphatic rupture (high pressure due to portal hypertension)

Question 5

What organisms cause SBP?

Answer 5

• Most organisms are gram negatives (E.coli, klebsiella, pseudomonas, enterbacteriaceae) and some gram positive (streptococcus, staphylococcus)

Question 6

should we use broad spectrum abs to treat SBP?

Answer 6

yes We need broad spectrum abx to cover this because it can be caused by gram negatives and gram positives.

Question 7

what are some Clinical Manifestations of SBP? (7)

Answer 7

1. fever
2. abdominal pain
3. AMS
4. diarrhea
5. paralytic ileus
6. hypotension
7. hypothermia

Question 8

what are the 2 most common manifestations of SBP?

Answer 8

fever and abdominal pain, fever can be low grade.

Question 9

Some patients with SBP are asymptomatic and are detected when they undergo _______ for another reason

Answer 9

paracentesis

Question 10

SBP is almost always associated with ______

Answer 10

chronic liver disease

Question 11

what 2 things do you need for a Definitive diagnosis is SBP?

Answer 11

o Positive ascitic fluid culture

o Elevated ascitic fluid absolute PMN count >250 cells/mm3

Question 12

When should you treat SBP empirically? (4)

Answer 12

o T >37.8°C (100°F)í this is considered a fever in chronic liver disease pts
o Abdominal pain and/or tenderness
o Change in mental status
o Ascitic fluid PMN count >250 cells/mm3

if they have any of these go ahead and treat

Question 13

if you are treating empirically for SBP, it is important that you still obtain what?

Answer 13

ascitic fluid for culture

Question 14

Up to date antibiotic choice for treating SBP

Answer 14

Cefotaxime (Claforan) IV

if they are pen allergic use:
levofloxacin (Levaquin) IV

Question 15

according to the Sanford Guide 2017, what antibiotics should you use to treat Community-acquired SBP?

Answer 15

Piperacillin-tazobactam (Zosyn) IV or ceftriaxone IV

if they are pen allergic use:
ciprofloxacin IV

Question 16

according to the Sanford Guide 2017, what antibiotics should you use to treat Nosocomial SBP?

Answer 16

Meropenem (carbopenem) IV or Daptomycin IV

Question 17

what is the length of Length of Antibiotic Therapy for SBP?

Answer 17

Minimum 5 days and stop if clinical improvement (is often significant)

Question 18

If fever or pain persists, repeat paracentesis, What should you do if PMN <250?

Answer 18

STOP tx

Question 19

If fever or pain persists, repeat paracentesis, what should you do if PMN is greater than pretreatment value?

Answer 19

look for surgical source

Question 20

If fever or pain persists, repeat paracentesis, what should you do if PMN is elevated but less than pretreatment?

Answer 20

continue antibiotics x 48 hours and repeat paracentesis

Question 21

what should you permanently discontinue if a pt has SBP?

Answer 21

nonselective beta blockers

Question 22

why should you stop BB in patients with SBP

Answer 22

o Higher mortality rates
o Increase rate of hepatorenal syndrome
o Longer length of hospital stays
o Decreasing cardiac output can worsen the conditions of pts with SBP and chronic cirrhosis

Question 23

what can you give to a patient with SBP to help reduce the risk of renal failure?

Answer 23

Albumin IV

Question 24

when can we use Albumin IV in a SBP pt?

Answer 24

• Creatinine >1 mg/dL
• BUN >30 mg/dL
• Total bilirubin >4 mg/dL

Question 25

Albumin expands/preserves plasma volume and thus preserves ______

Answer 25

renal function

Question 26

For prophylaxis of SBP, what therapy should we use other than abx?

Answer 26

o Diuretic therapy
o Recognize and treat other localized infections
o Restrict PPI use

Question 27

when is antibiotic prophylaxis warranted in SBP patients?

Answer 27

Recommended with advanced cirrhosis if at high risk (i.e., not all patients because it selects for resistant bacteria). Suggested indications:

1. Inpatients with ascitic fluid protein <1 g/dL
2. History of SBP episode(s)
3. Cirrhosis + GI bleed
4. Cirrhosis + ascites if:
   - Fluid protein <1.5 g/dL
   - Significant liver or renal disease

Question 28

if you are treating SBP prophylactically and the pt has a history of SBP, what abx should you use?

Answer 28

TMP/SMX daily

Alt: ciprofloxacin daily

Question 29

if you are treating SBP prophylactically and the pt is an inpatient and has cirrhosis with a GI bleed, how should you treat?

Answer 29

Ceftriaxone IV until bleeding under control then switch to TMP/SMX PO

Question 30

If FQ is used for prophylaxis can you use it for treatment?

Answer 30

NO

If FQ is used for prophylaxis DO NOT used FQ in treatment