Management / Evaluation of Spontaneous Bacterial Peritonitis

1. Spontaneous Bacterial Peritonitis
Maj Dr Babar Rafique
Trainee Medicine, Med Unit II
CMH Peshawar

2. Learning Objective:
Indications for abdominal paracentesis
Diagnosis of SBP
When to have repeated ascites paracentesis
Technique for collection of Ascitic fluid
Treatment of SBP
Candidates for SBP prophylaxis

3. SBP
 Infection of Ascitic fluid without an evident intra-abdominal
surgically treatable cause

4. Indications for Abdominal Paracentesis
in Patient with Ascites
Indication
New onset Ascites
At the time of each hospital admission
Clinical deterioration, inpatient /out patient
Fever, Abdominal pain/ Tenderness
Mental status change, ileus, Hypotension
Laboratory abnormalities that may indicate infection
Peripheral Leukocytosis
Acidosis
Worsening renal function
Gastrointestinal bleeding (a high time for infection)
Management of tense ascites or resistant Ascites
Runyon BA, AASLD. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult
patients with ascites due to cirrhosis 2012. Hepatology 2013; 57:1651.

5. Z track technique

6. Ordering Ascitic fluid examination
Specify the component being sought do not just write
ROUTINE EXAMINATION
If cytology is being ordered ensure that at least 20ml
sample is sent
Formalin preservative use if it would take >30 minutes
before being examined

7. Variants of SBP
• Culture +ve
• PMNs >250/mm3
SBP
• No growth
• PMNs >250/mm3
• Culture +ve
• PMNs <250/mm3
• Culture +ve
• PMNs <250/mm3
Monomicrobial
non-neutrocytic
ascites
(Bacterascites)
Culture –ve
Neutrocytic Ascites
Polymicrobial
Bacterascites

8. Variants of SBP
CULTURE –VE NEUTROCYTIC
ASCITES (PMNs >250/mm3)
Process that leads to death of cells and
activate complement system and attract
PMNs.
• Tuberculosis
• Malignancy related ascites
• Hemorrhage in to ascetic fluid
• Inadequate culture technique
• Unrecognized prior antibiotic use
• Late Paracentesis , SBP resolving

9. Variants of SBP
Bacterascites (Monomicrobial Non-
neutrocytic)
• Usually represents the colonization phase of infection
• Flora are similar to SBP
• 62-86% resolve spontaneously
• Patient destined to progress to SBP are febrile
• Culture should not be performed in asymptomatic
• Progression to SBP can occur rapidly

10. Variants of SBP
Polymicrobial Bacterascites
(PMNs <250/mm3)
• Traumatic paracentesis
• Usually transient
• Recognized by air or frank stool is aspirated
• Occur with inexperienced operator
• Needle is placed too close to surgical scar
• Surgical intervention almost never required

11. Pathogens
Organism Percentage of Isolates
Escherichia coli 43
Klebsiella pneumoniae 11
Streptococcus pneumoniae 9
Other streptococcal species 19
Enterobacteriaceae 4
Staphylococcus 3
Pseudomonas 1
Miscellaneous 10
Data from McHuchison JG, Runyon BA, Spontaneous bacterial peritonitis. in: Gastrointestinal and Hepatic Infections, Surawicz CM, Owen RL
(Eds), WB Saunders, Phliadelphia 1995. p.455.

12. Culture Technique
CNNA is largely due to insensitive culture
technique
Ascitic fluid has low microbial colony count and is
monomicrobial as bacteremia
Should be cultured as if it were blood (bedside
inoculation in culture bottles)
Increase sensitivity from 50% to 80%

13. Culture Technique
Similar to obtaining blood culture samples
• Site is cleaned
• Needle introduced and sample is drawn
• Needle of the syringe used is changed
• Cap of culture bottle is removed
• Wipe the tops of the culture bottles
• Samples are collected in both bottles
(aerobic and anaerobic organisms)

14. Culture Technique
0
2
4
6
8
10
1 ml (53%) 10-20 ml (97%)
sample vol
sample vol

15. Complication of Abdominal
Paracentesis
Complications Percetange
Leakage of Ascitic fluid 5
Severe hemorrhage 0 to 0.97
Infection due to paracentesis 0.58 to 0.63
Death associated with Paracentesis 0 to 0.39

16. High Risk Patients for SBP
Ascitic fluid protein concentration <1g/dl
Prior episode of SBP
Serum total bilirubin concentration above 2.5mg/dl
Variceal hemorrhage
Use of PPIs
Possibly malnutrition

17. High Risk Patients for SBP
with
Oror
• Creatinine
>1.2 mg/dl
• BUN >25mg/dl
• Na <130mEql/l
• Child-Pugh
score 9 with
• S. bilirubin
>3mg/dl
• Ascitic fluid
protein
concentration
<1.5 g/dl

18. Treatment Indications
Fever
Abdominal pain
Abdominal tenderness
Change in mental status/ deterioration of
consciousness
Ascetic fluid leukocyte count showing >250 PMNs/
mm3

19. Treatment of Bacterascites
Symptomatic
Treat
Asymptomatic
Repeat Ascitic
paracentesis after
48 hours
Treat
If becomes
symptomatic
Or
PMNs >250/mm3

20. Treatment in Alcoholics
These often have pain abdomen and peripheral
leukocytosis mimicking SBP
Symptomatic
PMNs
<250/mm3
Treat
Discontinue
treatment if
culture turn -ve

21. Before starting treatment:
1
• Send the Ascitic fluid sample for investigation
2
• Collection and processing of the sample should not
take >1-4 hours from the time of paracentesis
3
• Stop Beta Blockers
• Increase mortality 58%
• Increase incidence of HRS 24 vs 11%

22. Choice of Antibiotic
 Take into account
 Recent antibiotic use
 Local resistance pattern
 Narrow coverage once culture result available
 Open ended use of broad spectrum Antibiotics results in
selection of multiple resistant flora
 Resistance is especially a concern in those with
Quinolone prophylaxis

23. Treatment
SBP
Community Acquired
Cefotaxime or
Piperacillin-
Tazobactam
Health care
associated (low risk
for MDROs)
Piperacillin/
Tazobactam
Nosocomial (High risk
for MDROs)
Meropenam with
Glycopeptide or with
Daptomycin

24. Cefotaxime
Better than ceftriaxone
No dose adjustment is required in patients with Azotemia
4 g per day is as effective as 8 g per day
5 days of treatment is as effective as 10 days

25. Amoxicillin-calvulanic Acid
First given iv than orally
As effective as cefotaxime (mortality/resolution)
Low cost
 Risk of drug induced liver injury (DILI)

26. Quinolones
Levels achieved in Ascitic fluid is not equivalent to
cefotaxime
Can not be use in those with Quinolone prophylaxis
Uncomplicated SBP can be treated with
 Norfloxacin 400mg PO OD
Ciprofloxacin
 200mg IV BD for 02 day
 Followed by 500mg PO BD

27. Follow up Ascites Paracentesis
Done at 48 hours following start of treatment
Treatment failure
Worsening Sign/ symptoms
PMNs increased or failed to
decrease by 25%
IF
OR

28. Intravenous Albumin
Decreased incidence of type 1 HRS (30% to 10%)
Decreased mortality (29% to 10%) compared with
cefotaxime treatment alone
• Serum bilirubin >4mg/dl
• Serum creatinine >1mg/dl
IV Albumin 1.5g/kg at diagnosis
• Followed by 1g/kg on day three

29. Prophylaxis
High risk patients
Low Ascitic protein content ( <1g/dL )
Acute GI bleed
Previous history of SBP

30. Low Ascitic Protein Content
Norfloxacin 400mg /day
Ascitic protein <1
g/dL
Ascitic protein 1-1.5
g/dL
• S. bilirubin >3mg/dl
• CTP >9
• S. Cr >1.2mg/dl
• BUN >25
• S. Na <130
+
OR

31. Prophylaxis
Continuous Norfloxacin is superior to intermittent
(once weekly) Ciprofloxacin
Judicious use of PPIs
Patients on NSBBs should monitored regularly

32. Prognosis
Mortality is low among appropriately treated cases
In hospital mortality best predicted by renal
dysfunction (67% vs 11%) and high MELD scores
 Long term mortality is 70% at 01 year and 80% at
02 years
Liver transplant should be considered among
survivors of SBP

33. thanks