Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is a form of peritonitis that occurs in patients with cirrhosis. It occurs in 10-30% of hospitalized patients with ascites, and can cause marked decompensation of the liver disease, with other complications and death occurring frequently.

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Symptoms

Symptoms include fevers, chills, nausea, vomiting, abdominal tenderness and general malaise. Patients may complain of abdominal pain and worsening ascites. Hepatic encephalopathy may be the only manifestation of SBP; in the absence of a clear precipitant for the encephalopathy, all patients should undergo paracentesis, or sampling of the ascites fluid, in order to assess for SBP.

Diagnosis

Diagnosis necessitates paracentesis (needle drainage of the ascitic fluid) and laboratory confirmation of ascitic neutrophils > 250/mm³.

Treatment

Antibiotics

After confirmation of SBP, patients need hospital admission for intravenous antibiotics (most often cefotaxime given as 1gm/12hours for 5 days or ceftriaxone). They will often also receive intravenous albumin. A repeat paracentesis in 48 hours is sometimes performed to ensure control of infection. Once patients have recovered from SBP, they require regular prophylactic antibiotics (e.g. Septra DS, Cipro, norfloxicin) as long as they still have ascites.

Intravenous albumin

A randomized controlled trial found that intravenous albumin on the day of admission and on hospital day 3 can reduce renal impairment.^[1]

Prevention/screening

All cirrhotic patients might benefit from antibiotics if:

• Ascitic fluid protein <1.0 g/dL^[2]. Patients with fluid protein <15 g/L and either Child-Pugh score of at least 9 or impaired renal function may also benefit.^[3]
• Previous SBP^[4]

Cirrhotic patients admitted to the hospital should receive antibiotics if:

• They have bleeding esophageal varices^[5]

References