Updated: 12/21/2019

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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(M2.GI.16.4694) 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? Tested Concept

QID: 107874
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Nadolol

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Cefotaxime

100%

(2/2)

3

Penicillin

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(0/2)

4

Levofloxacin

0%

(0/2)

5

Gentamicin

0%

(0/2)

M 7 B

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