SPONTANEOUS BACTERIAL PERITONITIS
Spontaneous bacterial peritonitis infection of ascitic fluid occurs in the absence of an apparent intra-abdominal source of infection. It is seen with few exceptions in patients with ascites caused by chronic liver disease. Translocation of enteric bacteria across the gut wall or mesenteric lymphatics leads to seeding of the ascitic fluid, as may bacteremia from other sites. Approximately 25% of cirrhotic patients with ascites develop spontaneous peritonitis; however, the incidence is greater than 40% in patients with ascitic fluid total protein less than 1 g/dL, probably due to decreased ascitic fluid opsonic activity.
All cases of spontaneous bacterial peritonitis are caused by a monomicrobial infection. The most common pathogens are enteric gram negative bacteria like (Klebsiella pneumoniae, E coli) and gram positive bacteria like (Viridans streptococci, Enterococcus species, Streptococcus pneumoniae). Anaerobic bacteria are not associated with spontaneous bacterial peritonitis.
Mostly patients with spontaneous bacterial peritonitis is symptomatic. The most common symptoms are abdominal pain and fever in mostly patients
Spontaneous bacterial peritonitis must be distinguished from secondary bacterial peritonitis, in which ascitic fluid has become secondarily infected by an intra abdominal infection. Causes of secondary bacterial peritonitis like diverticulitis, perforated peptic ulcer, and perforated gallbladder, appendicitis.
Ascitic fluid total protein, LD, and glucose are useful in distinguishing spontaneous bacterial peritonitis from secondary infection. . The presence of multiple organisms on ascitic fluid Gram stain or culture is diagnostic of secondary peritonitis.
If secondary bacterial peritonitis is suspected, abdominal CT imaging of the upper and lower gastrointestinal tracts should be obtained to look for evidence of an intra abdominal source of infection.
TREATMENT
Empiric therapy for spontaneous bacterial peritonitis should be initiated with a 3rd generation cephalosporin such as cefotaxime, or ceftriaxone, or a combination beta lactam/beta lactamase agent such as ampicillin/ sulbactam.
Because of a high risk of nephrotoxicity in patients with chronic liver disease, aminoglycosides should not be used. A course of 5-10 days is recommended, or treatment until the ascites fluid PMN count decreased. Patients without significant clinical improvement after 5 days should undergo repeat paracentesis to assess treatment efficacy. If the ascitic neutrophil count has not decreased by 25%, antibiotic coverage should be adjusted by culture and sensitivity evaluation and secondary causes of peritonitis excluded.
Patients with suspected secondary bacterial peritonitis should be given broad-spectrum coverage for enteric aerobic and anaerobic flora with a third-generation cephalosporin and metronidazole.
Intravenous use of albumin increases effective renal perfusion and arterial circulating volume, decreasing kidney injury and mortality.
Patients who survive an episode of spontaneous bacterial peritonitis will have another episode within 1 year. Oral once-daily prophylactic therapy with norfloxacin, 400 mg, ciprofloxacin, 250-500 mg, or trimethoprim sulfamethoxazole is recommended. Prophylaxis should be considered also in patients who have not had prior bacterial peritonitis but are at increased risk of infection due to low protein ascites.
For Informational purpose only. Consult your Physician for advice.
