- Bacterial infection of ascitic fluid without an obvious source
- Mortality rate can be greater than 20%
- Usually signifies advanced disease
- Organisms:
- Enteric – E.coli, K. pneumoniae
- S. aureus
- Hospital acquired infections have increased risk of resistance
SBP Specific Symptoms
- Abdominal pain
- Tenderness on palpation
- Ileus
- BUT
- Up to 1/3 of patients may be asymptomatic
- Present with AMS and/or AKI
- A diagnostic paracentesis should be obtained to evaluate ascitic fluid even in the absence of infectious symptoms
Diagnostic Paracentesis
- Evaluation of ascitic fluid:
- Cell count:
- Polymorphonuclear leukocyte (PMN) count ≥ 250 cells/mm3 indicative of SBP
- Cultures:
- Ideally isolate organism to guide antibiotic therapy
- Difficult, even more so after antibiotics have been given
- ALWAYS obtain paracentesis prior to initiating therapy
- Also recommended to obtain blood cultures
- If PMN count < 250 cells/mm3 with positive cultures but no s/sx of infection à no antibiotics
- Cell count:
TREATMENT | |
Antibiotics | •3rd Generation cephalosporin for 5 days:
•Cefotaxime 2g q8h •Ceftriaxone 1g q12h •Alternate: •Ofloxacin 400mg BID |
Albumin | Reduce risk of renal failure:
•Day 1: 1.5 mg/kg within 6 hours of presentation •Day 3: 1 mg/kg Also give when: •Scr > 1 mg/dl •BUN > 30 •Total bilirubin > 4 |
Monitoring for Improvement
- Though not routinely done in practice, you can assess for empiric antibiotic response with repeat paracentesis
- 2 days after antibiotic initiation
- Expect a 25% decrease in PMN from baseline
- Lack of PMN decrease may indicate antibiotic failure, and broader antibiotic therapy may be needed
Prevention of Recurrent SBP
- Once a patient with cirrhosis has developed SBP, they are at increased risk for redevelopment (secondary prevention)
- Individuals who have had an episode of SBP should be provided prophylactic antibiotics to prevent the development of an additional episode
“SECONDARY” PREVENTION | |
Antibiotics | •Norfloxacin (no longer available in US), Ciprofloxacin, or Bactrim
•Bactrim: 1 DS tablet daily •Ciprofloxacin: 500mg daily |
Monitoring | •Bactrim: renal function, hyperkalemia, DDI’s
•Ciprofloxacin: renal dose adjustments, QTc monitoring |