Updated: 9/10/2019

Spontaneous Bacterial Peritonitis (SBP)

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Snapshot
  • A 46-year-old man with chronic alcohol abuse and advanced cirrhosis presents with worsening abdominal pain and confusion. On evaluation in the emergency room, his temperature is 101.4°F (38.6°C), blood pressure is 125/80 mmHg, pulse is 106/min, and respirations are 22/min. On physical exam, there is abdominal distension with a fluid wave and diffuse abdominal tenderness to palpation with rebound tenderness.
Introduction
  • Clinical definition
    • acute bacterial infection of the peritoneum without obvious focal source
  • Epidemiology
    • occurs in up to 20% of patients with ascites
    • high recurrence rate
    • most commonly from a single organism
      • Escherichia coli
      • Klebsiella pneumoniae
      • Streptococcus pneumoniae
  • Pathogenesis
    • controversial mechanism of inoculation
      • bacterial translocation from the gut
      • hematogenous transmission
      • immune compromise
  • Associated conditions
    • alcohol cirrhosis
    • heart failure
    • Budd-Chiari
    • nephrosis
    • systemic lupus erythematosus
Presentation
  • Symptoms
    • confusion
    • abdominal pain
    • fever
    • vomiting
    • diarrhea
  • Physical exam
    • febrile
    • abdominal tenderness and rebound tenderness
    • distended abdomen with fluid wave
    • flank dullness
Studies
  • Diagnostic testing
    • peritoneal fluid analysis
      • diagnostic paracentesis or via peritoneal catheter 
        • ultrasound guided if needed
      • white blood cell count ≥ 500 cells/uL
      • neutrophil count ≥ 250 cells/µL
      • Gram stain and culture
        • can be positive or negative
      • pH
      • lactate
      • serum ascites albumin gradient (SAAG) > 1.1
    • ancillary
      • blood culture
      • urine culture
      • complete blood count
      • chemistries
Differential
  • Secondary peritonitis
    • distinguishing factor
      • due to a focal intraabdominal process
        • perforated viscus
        • abscess
  • Nephrolithiasis
    • distinguishing factor
      • nephroliths on imaging
Treatment
  • Management approach
    • discontinue nonselective β-blockers
    • start with empiric antibiotics after paracentesis
    • narrow according to cultures, if available
    • albumin infusion
  • First-line antibiotic
    • 3rd generation cephalosporin
      • cefotaxime or ceftriaxone
Complications
  • Renal failure
  • Sepsis and septic shock
  • Death
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GI.4694) A 56-year-old African American male presents with altered mental status, abdominal pain, and a fever of 100.4F. His past medical history is significant for alcohol use and cirrhosis of the liver. Shifting dullness is noted on physical exam. Paracentesis demonstrates serum ascites albumen gradient of 1.3 g/dL, and the ascitic fluid polymorphonuclear cell count is 280 cells/mm^3. Which of the following is the best treatment for this patient’s condition while waiting for the ascitic fluid culture results? Review Topic

QID: 107874
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Nadolol

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Cefotaxime

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Penicillin

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Levofloxacin

0%

(0/0)

5

Gentamicin

0%

(0/0)

M2

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