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Spontaneous Bacterial Peritonitis

HISTORY
In 1971, Conn and Fessel described a syndrome of infected ascitic fluid in patients with hepatic cirrhosis, which they named SBP.

CLEVELAND JOURNAL OF MEDICINE VOL 71.NUMBER 7.JULY2004

What is Spontaneous Bacterial Peritonitis ?

SBP is by definition an infection of previously sterile ascitic fluid, without any apparent intra-abdominal source of infection. The infecting organisms are usually those found among the normal intestinal flora.
CLEVELAND JOURNAL OF MEDICINE VOL 71.NUMBER 7.JULY2004

Incidence
Patients with cirrhosis are very suspectible to infection of ascitic fluid as apart of their general suspectibility to infection.

Approx 20-30% of cirrhotic patients with ascites develop spontaneous bacterial peritionitis.1

*1,2 Journal of Medicine, July 2004

A Prevalent and Deadly Disease


Year Prevalence in Cirrhotic patients

1970

5-10%

1987-1993

10-30%

CLEVELAND JOURNAL OF MEDICINE VOL 71.NUMBER 7.JULY 2004

Factors Mortality
SBP is deadly
Development of Renal Failure Hepatic encephalopathy High levels of serum Bilirubin Upper GI bleeding

CLEVELAND JOURNAL OF MEDICINE VOL 71.NUMBER 7.JULY 2004

Factors Mortality
SBP is deadly
Development of renal impairment after the diagnosis of SBP is probably the strongest independent predictor of death

In 252 consecutive episodes of SBP, the mortality rate was 100 %


when associated with progressive renal impairment

CLEVELAND JOURNAL OF MEDICINE VOL 71.NUMBER 7.JULY 2004

Damage to the intestinal barrier leads to bacterial translocation and endotoxaemia and thus to impairment of liver function and increase in portal pressure, possibly causing further damage to the gut: a vicious circle.

A vicious circle

Microbiology
The pathogens responsible for the spontaneous bacterial peritionitis are Enteric gram-negative bacteria E.coli, Klebsiella pneumonia, Enterococcus species, Gram-positive bacteria Streptococcus pneumonia, Virdans streptococci

ANEROBIC BACTERIA ARE NOT ASSOCIATED WITH SPONTANEOUS BACTERIAL PERITIONITIS


CLEVELAND JOURNAL OF MEDICINE VOL 71.NUMBER 7.JULY2004

Signs and Symptoms


The presentation depends on the stage of the disease, and because the signs and symptoms are nonspecific
80-90% are symptomatic and a subtle presentation,

Fever and abdomianl pain,


Change in mental status due to exacerbation or precipation of hepatic encephalopathy, Worsening of renal function, Abdominal tenderness is present in < 50 % of the patients. About one-third presents with diarrohea or paralytic ileus, Hypothermia and hypotension is present in <20% of patients, Physical signs demonstrates signs of chronic liver disease with ascites,
CLEVELAND JOURNAL OF MEDICINE VOL 71.NUMBER 7.JULY2004

MANAGEMENT
The presentation depends on the stage at which the infection is diagnosed In the early stages , most patients are asymptomatic As the disease progresses, patients show signs and symptoms of peritoneal infection

CLEVELAND JOURNAL OF MEDICINE VOL 71.NUMBER 7.JULY 2004

DIAGNOSIS
The diagnosis relies on laboratory and microbiological tests. Currently, paracentesis with laboratory testing the ascitic fluid is the only way to confirm and rule out SBP in patients with cirrhosis.

JOURNAL OF HEPATOLOGY July2000;120:726

Diagnosis

Diagnostic paracentesis should therefore be performed in:


Any patient with new-onset ascites, including patients with congestive heart failure or Budd-Chiari syndrome Any cirrhotic patient with ascites who develops symptoms such as unexplained encephalopathy or renal failure Any patient with stable cirrhosis and ascites whose condition deteriorates suddenly.

If SBP is suspected in a patient with clinically undetectable ascites, ultrasonography is indicated to identify the ascites and to perform guided paracentesis.
I nternational Journal of Gastroenterology and Hepatology 2005;54:1523-1526

Diagnosis

A polymorphonuclear cell count of more than 250 / mm3 in ascitic fluid is currently considered diagnostic of SBP and warrants the prompt start of antibiotic treatment

CLEVELAND JOURNAL OF MEDICINE VOL 71.NUMBER 7.JULY 2004

PROGNOSIS

The mortality rate of SBP exceeds > 30%, but if the disease is recognized and treated earlier, the rate is < 10%. Majority of patients have underlying severe liver disease, and may die of liver failure, hepato-renal syndrome, or bleeding complications from portal hypertension.

Treatment
Antibiotic Regimens In Evolution

Initially, the regimen most often used to treat SBP was a beta-lactam such as ampicillin or cephalotin, and an amninoglycoside such as gentamycin or tobrarmycin. However, in the first randomized comparative study of two different regimens for SBP, cefotaxime was superior to ampicillin plus tobramycin for resolving SBP. In that study, ampicillin plus tobramycin was also associated with nephrotoxicity or superinfections in approximately 10% of patients.

Several studies have since confirmed the effectiveness of cefotaxime in patients with SBP
Cleveland journal of medicine vol 71 number 7 july 2004.

Treatment

Starting empiric antibiotic therapy immediately improves survival in SBP, although mortality rate is still about 10% - 30% and those who survive are at high risk of a recurrence

CLEVELAND JOURNAL OF MEDICINE VOL 71.NUMBER 7.JULY 2004

Treatment

Empiric antibiotic treatment should be started once the polymorphonuclear cell count in ascitic fluid exceeds 250 / mm 3

CLEVELAND JOURNAL OF MEDICINE VOL 71.NUMBER 7.JULY 2004

Duration of Therapy

Ten to 14 days of intravenous (IV) antibiotics is the standard treatment.

(Journal of Gastroenterology 1991)

TREATMENT
At present, third-generation cephalosporins are considered the gold standard in the treatment of SBP in cirrhosis. Cefotaxime is considered to be one of the first-choice antibiotic therapies in the empirical treatment of SBP in patients with cirrhosis.

International Journal of Gastroenterology and Hepatology 2005;54:1523-1526

PROPHYLAXIS
At present, third-generation cephalosporins are considered the gold standard in the treatment of SBP in cirrhosis. Cefotaxime is considered to be one of the first-choice antibiotic therapies in the empirical treatment of SBP in patients with cirrhosis.

International Journal of Gastroenterology and Hepatology 2005;54:1523-1526

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