spontaneous bacterial peritonitis

1. Dr Ishatir Radiyate Ranu
Intern Doctor
Medicine unit:7
Dhaka Medical College And Hospital

2. Spontaneous bacterial peritonitis is defined as an
ascitic fluid infection without an evident intra-
abdominal surgically treatable source.
SBP is the most common bacterial infection in patients
with cirrhosis – results from translocation of bacteria
from intestine into ascitic fluid.

3. 1)Translocation: Gut bacteria traverse the intestinal
wall and colonize in mesenteric lymph nodes.
2) Bacterascites can occur if the lymphatic carrying
the contaminated lymph ruptures – due to high flow
and high pressure associated with portal
hypertension.

4. 3) Alternatively, mesenteric lymphatics ->systemic
circulation -> percolate through the liver -> weep across
Glisson’s capsule to enter the ascetic fluid.
4) Hematogenous :bacteria causing SBP can also
originate in sites other than the gut via bacteremic
seeding.

5.  Most cases of SBP are due to gut bacteria such as
Escherichia coli and Klebsiella, though Streptococcal
and Staphylococcal infections can also occur.
 As a result ,broad-spectrum therapy is warranted until
the results of susceptibility testing are available.

6. • Advanced cirrhosis
• paracentasis
• GI bleeding
• Proton pump inhibitor (decrese phagocyte oxidative
burst)
• UTIs
• Deficient ascetic fluid bactericidal activity – AF c3 level
<13mg/dl or AF total protein <1gm/dl

7. • Serum total bilirubin concentration above 2.5 mg/dl
• Previous episode of SBP

8. • Abdominal pain or fever in a patient with obvious
features of cirrhosis and ascites. However ,abdominal
signs are mild or absent in about one-third of patients.
• Hepatic encephalopathy
• Non specific deteriorations
• Associated with a high rate of acute kidney injury and
mortality.

9. • Clinical features
• Diagnostic paracentesis: 1)may show cloudy fluid,
2) ascites neutrophil count >250*10^6 /L almost
invariably indicates infection, 3) positive ascitic culture.

10.  Start as early as possible
 Indication of starting emprirical antibiotic therapy:
 Fever >100.4F
 Abdominal pain or tenderness
 Altered mental status

11.  Prefarably a third generation cephalosporins
intravenously:
i. Cefotaxime 2 gm 8 hourly
ii. Ceftriaxone 2gm/day when cefotaxime is not
available.
iii. In case of resistance to third generation
cephalosporins, piperacillin-tazobactam or
carbapenems are the antibiotic of choice.

12. • Usually a 5 days antibiotic regimen is practiced
• Treating until 48 hours after the signs and symptoms
have disappeared is also effective.
• Longer treatment is considerd in:
 Unusal organisms like Pseudomonas
 Resistant organisms
 Organisms associated with endocarditis (eg. Staph
aureus or Viridans streptococcus)

13. • Discontinue non selective beta blockers: among pt
with SBP ,beta blocker use is associated with worse
outcomes compared with those not receiving beta
blocker.
• Albumin administration for patients with jaundice or
renal dysfunction: renal failure develops in 30 to 40
percent of patients with SBP and is a major cause of
death.

14.  Renal impairement is to be treated with intravenous
infusion of 25% albumin solution,administered
within 6 hrs of diagnosis – 1.5gm/kg body weight on
1st day and 1gm/kg body weight on 3rd day
(maximum dose 100g)
 Once renal failure has developed, treating with
octreotide and midodrine may be helpful.

15. Patient with bacterascites: in some patients, infection is
detected at the bacterascites stage ie. Bacteria are
present in the ascetic fluid, but the PMN count is
<250cells/microL.
i. In symptomatic patient – start treatment
ii. If patient is asymptomatic, repeat paracentesis after 48
hrs and treatment is initiated if the PMN count has risen
to >250cells/microL.

16.  Secondary bacterial peritonitis and polymicrobial
infections: should consider broader coverage with
cefotaxime and metronidazole and surgical
intervention in secondary peritonitis is a must.
 Culture-negative neutrocytic ascites: pt with an
ascetic fluid PMN count >250cells/microL but have
negative ascetic fluid culture. As most of such
patients have SBP,they should be treated with
empirical antibiotic.

17. o To prevent recurrent SBP
o Choice of antibiotic: Norfloxacin 400mg/day or
ciprofloxacin 750mg/week or cotrimoxazole
960mg/day
o Primry antibiotic prophylaxis also reduces the
incidence of SBP in patients with low ascetic protein
<15g/L

18.  All admitted patient should undergo diagnostic
paracentesis unless contraindicated.
 Try to rule out secondary causes in all possible cases
 Early antibiotic therapy grossly alters the final outcome
 Primary prophylaxis has a role in preventing systemic
complications and improving survival.

19. Thank You

20.  Davidson’s Principles And Practice of Medicine, 24th edition
 American Association For The Study Of Liver Diseases (AASLD)
Guideline, 2021