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Updated: Dec 17 2021

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
    • Associated conditions
      • alcohol cirrhosis
      • heart failure
      • Budd-Chiari
      • nephrosis
      • systemic lupus erythematosus
  • 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
  • ETIOLOGY
    • Pathogenesis
      • controversial mechanism of inoculation
        • bacterial translocation from the gut
        • hematogenous transmission
        • immune compromise
  • 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
          • cefotaxime preferred in patients with liver failure as it is renally excreted whereas ceftriaxone is hepatically cleared 
  • Complications
    • Renal failure
    • Sepsis and septic shock
    • Death
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