SBP

Definition

SBP is a bacterial infection of the ascitic fluid.

Diagnosis:

PMN count >= 250 cells/mm³ OR ascitic fluid WBC >= 500 cells/mm³ with a positive fluid culture.

Diagnostic clinical signs: New onset fever, confusion or abdominal pain, hepatic encephalopathy, vomiting, diarrhea.

Diagnosis of Culture-negative neutrocytic ascites: PMN count >= 250 cells/mm³ with a negative fluid culture (subtract 1 PMH for every 250 RBCs).

Pathogens causing SBP: Common organisms are E. coli, Klebsiella pneumoniae, Enterobacteriaceae, Streptococcus pneumoniae, and Enterococcus.

Patients with Cirrhosis: Cirrhotic patients can also get secondary bacterial peritonitis, which usually requires surgical intervention. One should suspect secondary peritonitis with perforation if the ascitic fluid meets 2 or more of the following: Total WBC >10,000, Total protein > 1 g/dl, Glucose < 50 mg/dl OR LDH > 225 milliunits/ml (or higher than upper normal for serum). One should also be suspicious if multiple organisms are cultured or if there is a failure to improve after 48 hours of standard therapy.

Risk Factors for SPB: Severe liver disease, GI hemorrhage, Prior SBP, Ascitic fluid protein <= 1 g/dl.

Diagnosis of SBP: Abdominal paracentesis, send fluid for cell count and differential and send fluid directly in the culture bottles.

Treatment for SBP:

Start antibiotic therapy as soon as the diagnosis of SBP is made based on fluid PMN count OR earlier if clinically indicated.

Use a third-generation cephalosporin (cefotaxime or a similar third generation cephalosporin) HIGH dose 2gm every 8 hours for 5 days.

Any person with cirrhosis and ascites who has signs or symptoms concerning for SBP should be treated with antibiotic therapy regardless of ascites fluid PMN count.

Antibiotic Prophylaxis for SBP: Prophylaxis should be given to persons with cirrhosis with a prior history of SBP or acute GI bleeding and should be considered in those who have renal or hepatic dysfunction if total ascitic fluid protein is less than 1.5g/dL.

Primary and Secondary SBP Prophylaxis: Ciprofloxacin 500 mg daily or trimethoprim-sulfamethoxazole one double strength tablet daily.  If patient has cirrhosis and acute GI hemorrhage, IV ceftriaxone 1 gram daily is recommended for a total duration of 7 days.