1. Spontaneous Bacterial Peritonitis Katherine Yu May 2014

2. Objectives Know how to diagnose spontaneous bacterial peritonitis (SBP) Know how to treat SBP Know the indications for the primary prophylaxis of SBP and the treatment regimen

3. Case A 45 year old man is admitted to the hospital for a two day history of fever and abdominal pain. His medical history is notable for cirrhosis due to chronic hepatitis C, esophageal varices, ascites, and minimal hepatic encephalopathy. On physical exam, T 36.5C, BP 100/50, P 84, RR 20. BMI 28. Abdominal exam discloses distension consistent with ascites. Labs: WBC 3.5, Hgb 10, Plt 70. Cr 1.8. Total bilirubin 4. ALT 30, AST 40. Diagnostic paracentesis discloses a cell count of 2,000/microliter with 20% neutrophils, a total protein level 1 g/dL, and an albumin of 0.7 g/dL. Ascitic fluid culture is positive. What is his diagnosis? What is the most appropriate treatment?

4. Diagnosis SBP is diagnosed by an ascites cell count of ≥ 250 PMNs/mm 3 and a positive ascitic fluid culture How to calculate the number of PMNs in ascitic fluid: Ascitic fluid cell count multiplied by the percentage of PMNs Example: Ascitic fluid cell count is 1,000 and there are 30% PMNs The number of PMNs is 1,000 x 0.3 = 300

5. Diagnosis TypeAscites cell count/mm 3 Ascites culture Spontaneous bacterial peritonitis (SBP) ≥ 250 PMNsUsually polymicrobial. Microbiology: 70% GNR (E. coli, Klebsiella), 30% GPC (enterococcus, S. pneumo). Less commonly nosocomial (fungi, pseudomonas) Be aware there is also culture negative neutrocytic ascites (CNNA) with ≥ 250 PMNs/mm 3 but with negative ascites culture.

6. Treatment Cefotaxime 2 gm IV q8 hours for 5 days Oral fluoroquinolone can be used for uncomplicated SBP (stable renal and hepatic function and no encephalopathy) The addition of IV albumin 1.5 g/kg at the time of diagnosis and 1 g/kg on day three may increase survival and reduce the rate of renal impairment when compared with antibiotics alone If patient is not improving, consider repeat paracentesis at 48 hours

7. Indications for Prophylaxis Primary prophylaxis: If ascitic fluid total protein (AFTP) 1.2 or Child-Pugh score B Secondary prophylaxis: If prior history of SBP Regimen: norfloxacin 400 mg po daily -OR - Bactrim DS daily Benefits of prophylaxis: Improves 1 year survival probability Reduces 1 year probability of SBP

8. Back to the case A 45 year old man is admitted to the hospital for a two day history of fever and abdominal pain. His medical history is notable for cirrhosis due to chronic hepatitis C, esophageal varices, ascites, and minimal hepatic encephalopathy. On physical exam, T 36.5C, BP 100/50, P 84, RR 20. BMI 28. Abdominal exam discloses distension consistent with ascites. Labs: WBC 3.5, Hgb 10, Plt 70. Cr 1.8. Total bilirubin 4. ALT 30, AST 40. Diagnostic paracentesis discloses a cell count of 2,000/microliter with 20% neutrophils, a total protein level 1 g/dL, and an albumin of 0.7 g/dL. Ascitic fluid culture is positive. What is his diagnosis? What is the most appropriate treatment?

9. Summary Spontaneous bacterial peritonitis (SBP) is diagnosed by an ascites fluid cell count of ≥ 250 PMNs and a positive ascites fluid culture. Treatment of SBP is IV cefotaxime 2 gm IV q8 hours and IV albumin 1.5 g/kg on day one and 1 g/kg on day 3. The concomitant use of albumin with antibiotic therapy is associated with a survival benefit compared with antibiotic therapy alone. Primary prophylaxis of SBP is indicated if ascitic fluid total protein (AFTP) 1.2 or Child-Pugh score B. The treatment is daily oral norfloxacin or Bactrim DS.