Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis
Specialty Gastroenterology Edit this on Wikidata

Spontaneous bacterial peritonitis (SBP) is the development of a bacterial infection in the peritoneum causing peritonitis, despite the absence of an obvious source for the infection.[1] It occurs almost exclusively in people with cirrhosis of the liver.[1] It can also occur in patients with nephrotic syndrome.[2][3] SBP has a high mortality rate.[4]

The diagnosis of SBP requires paracentesis, a sampling of the peritoneal fluid taken from the peritoneal cavity.[5] If the fluid contains large numbers of white blood cells known as neutrophils (>250 cells/µL), infection is confirmed and antibiotics will be given, and investigation into the bacteria that will be present is not necessary.[6] In addition to antibiotics, infusions of albumin are usually administered.[6]

Spontaneous fungal peritonitis (SFP) can also occur and this can sometimes accompany a bacterial infection.[7]

Signs and symptoms

Signs and symptoms of spontaneous bacterial peritonitis (SBP) include fevers, chills, nausea, vomiting, abdominal tenderness, and general malaise.[1] Affected individuals may complain of abdominal pain and worsening ascites.[1] Thirteen percent of patients have no signs or symptoms.[8] Hepatic encephalopathy may be the only manifestation of SBP; in the absence of a clear precipitant for the encephalopathy, all patients should undergo paracentesis, or sampling of the ascites fluid, in order to assess for SBP.

These symptoms can also be the same for a spontaneous fungal peritonitis (SFP) and therefore make a differentiation difficult. Delay of diagnosis can delay antifungal treatment and lead to a higher mortality rate.[7]

Causes

Infection of the peritoneal fluid with gram-negative bacteria, mostly E. coli and Klebsiella, is the most common cause of SBP.[6] Gram-positive cocci species, such as streptococci and staphylococci, have historically been responsible for less than 25% of SBP cases though the incidence of such cases has been increasing.[6] Anaerobic and fungal infections of the ascitic fluid are rare but have been reported with organisms such as Aeromonas, Bordetella bronchiseptica, Candida species, Salmonella paratyphi A, and Pasteurella multocida.[6]

Pathophysiology

SBP is thought to result from a combination of factors inherent in cirrhosis and ascites, such as prolonged bacteremia secondary to compromised host defenses, intrahepatic shunting of colonized blood, and defective bactericidal activity within the ascitic fluid.[9] Suppression of the stomach's secretion of acid, such as by proton pump inhibitor medications, has also been associated with SBP in patients with advanced cirrhosis.[10][11][12] Bacterial translocation is thought to be the key mechanism for the development of SBP.[13] With respect to compromised host defenses, patients with severe acute or chronic liver disease are often deficient in complement and may also have malfunctioning of the neutrophilic and reticuloendothelial systems.[14]

As for the significance of ascitic fluid proteins, it was demonstrated that cirrhotic patients with ascitic protein concentrations below 1 g/dL were 10 times more likely to develop SBP than individuals with higher concentrations.[15] It is thought that the antibacterial, or opsonic, activity of ascitic fluid is closely correlated with the protein concentration.[16] Additional studies have confirmed the validity of the ascitic fluid protein concentration as the best predictor of the first episode of SBP.[14]

Diagnosis

Infection of the peritoneum causes an inflammatory reaction with a subsequent increase in the number of neutrophils in the fluid.[4] Diagnosis is made by paracentesis (needle aspiration of the ascitic fluid). SBP is diagnosed if the fluid contains neutrophils (a type of white blood cell) at greater than 250 cells per mm3 (equals a cell count of 250 x106/L) fluid in the absence of another reason for this (such as inflammation of one of the internal organs or a perforation).[1][17] The fluid is also cultured to identify bacteria. If the sample is sent in a plain sterile container 40% of samples will identify an organism, while if the sample is sent in a bottle with culture medium the sensitivity increases to 72–90%.[17]

Prevention

All people with cirrhosis might benefit from antibiotics (oral fluoroquinolone norfloxacin) if:

  • Ascitic fluid protein <1.0 g/dL.[15] Patients with fluid protein <15 g/L and either Child-Pugh score of at least 9 or impaired renal function may also benefit.[18]
  • Previous SBP[19]

People with cirrhosis admitted to the hospital should receive prophylactic antibiotics if:

Treatment

Antibiotics

Although there is no high-quality evidence, the third generation cephalosporins are considered the standard empirical treatment for spontaneous bacterial peritonitis in people with cirrhosis.[21] In practice, cefotaxime is the agent of choice for treatment of SBP. After confirmation of SBP, hospital admission is usually advised for observation and intravenous antibiotics. Intravenous albumin is usually administered too. Paracentesis may be repeated after 48 hours to ensure control of infection. After recovery from SBP, indefinite prophylactic antibiotics are recommended.

Prokinetics

The addition of a prokinetic drug to an antibiotic regimen reduces the incidence of spontaneous bacterial peritonitis possibly via decreasing small intestinal bacterial overgrowth.[22]

Intravenous albumin

A randomized controlled trial found that intravenous albumin on the day of admission and on hospital day 3 can reduce kidney impairment.[23]

Epidemiology

Patients with ascites underwent routine paracentesis, the incidence of active SBP ranged from 10% to 27% at the time of hospital admission.[24]

History

SBP was first described in 1964 by Harold O. Conn.[25]

References

  1. 1 2 3 4 5 Lata J, Stiburek O, Kopacova M (November 2009). "Spontaneous bacterial peritonitis: a severe complication of liver cirrhosis". World J. Gastroenterol. 15 (44): 5505–10. doi:10.3748/wjg.15.5505. PMC 2785051. PMID 19938187.
  2. ↑ Hingorani SR, Weiss NS, Watkins SL (August 2002). "Predictors of peritonitis in children with nephrotic syndrome". Pediatr. Nephrol. 17 (8): 678–82. doi:10.1007/s00467-002-0890-6. PMID 12185481.
  3. ↑ Teo, S; Walker, A; Steer, A (December 2013). "Spontaneous bacterial peritonitis as a presenting feature of nephrotic syndrome". Journal of Paediatrics and Child Health (Review). 49 (12): 1069–71. doi:10.1111/jpc.12389. PMID 24118585.
  4. 1 2 MacIntosh, T (1 March 2018). "Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review". Cureus. 10 (3): e2253. doi:10.7759/cureus.2253. PMID 29721399.
  5. ↑ Rimola A, García-Tsao G, Navasa M, et al. (January 2000). "Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club". J. Hepatol. 32 (1): 142–53. doi:10.1016/S0168-8278(00)80201-9. PMID 10673079.
  6. 1 2 3 4 5 Dever, JB; Sheikh, MY (June 2015). "Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention". Alimentary Pharmacology & Therapeutics (Review). 41 (11): 1116–31. doi:10.1111/apt.13172. PMID 25819304.
  7. 1 2 Shizuma, T (27 February 2018). "Spontaneous bacterial and fungal peritonitis in patients with liver cirrhosis: A literature review". World journal of hepatology. 10 (2): 254–266. doi:10.4254/wjh.v10.i2.254. PMID 29527261.
  8. ↑ Koulaouzidis A, Bhat S, Saeed AA (March 2009). "Spontaneous bacterial peritonitis". World J. Gastroenterol. 15 (9): 1042–9. doi:10.3748/wjg.15.1042. PMC 2655193. PMID 19266595.
  9. ↑ Runyon BA, Hoefs JC (1984). "Culture-negative neutrocytic ascites: a variant of spontaneous bacterial peritonitis". Hepatology. 4 (6): 1209–11. doi:10.1002/hep.1840040619. PMID 6500513.
  10. ↑ Gati GA, Deshpande A (2012). "Increased rate of spontaneous bacterial peritonitis among cirrhotic patients receiving pharmacologic acid suppression". Clinical Gastroenterology and Hepatology. 10 (4): 422–27. doi:10.1016/j.cgh.2011.11.019. PMID 22155557.
  11. ↑ Deshpande A, Pasupuleti V (2012). "Acid suppressive therapy is associated with spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis". Journal of Gastroenterology and Hepatology. 28 (2): 235–42. doi:10.1111/jgh.12065. PMID 23190338.
  12. ↑ Bajaj JS, Zadvornova Y (2009). "Association of Proton Pump Inhibitor Therapy With Spontaneous Bacterial Peritonitis in Cirrhotic Patients With Ascites". American Journal of Gastroenterology. 104 (5): 1130–34. doi:10.1038/ajg.2009.80. PMID 19337238.
  13. ↑ Koulaouzidis, A; Bhat, S; Saeed, AA (7 March 2009). "Spontaneous bacterial peritonitis". World journal of gastroenterology. 15 (9): 1042–9. PMID 19266595.
  14. 1 2 Alaniz C, Regal RE (April 2009). "Spontaneous Bacterial Peritonitis: A Review of Treatment Options". P T. 34 (4): 204–210. PMC 2697093. PMID 19561863.
  15. 1 2 Runyon BA (December 1986). "Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis". Gastroenterology. 91 (6): 1343–6. PMID 3770358.
  16. ↑ Runyon BA, Morrissey RL, Hoefs JC, Wyle FA (1985). "Opsonic activity of human ascitic fluid: a potentially important protective mechanism against spontaneous bacterial peritonitis". Hepatology. 5 (4): 634–7. doi:10.1002/hep.1840050419. PMID 4018735.
  17. 1 2 Moore KP, Aithal GP (October 2006). "Guidelines on the management of ascites in cirrhosis". Gut. 55 (Suppl 6): vi1–12. doi:10.1136/gut.2006.099580. PMC 1860002. PMID 16966752.
  18. ↑ Fernández J, Navasa M, Planas R, et al. (2007). "Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis". Gastroenterology. 133 (3): 818–24. doi:10.1053/j.gastro.2007.06.065. PMID 17854593.
  19. ↑ Grangé JD, Roulot D, Pelletier G, et al. (1998). "Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites: a double-blind randomized trial". J. Hepatol. 29 (3): 430–6. doi:10.1016/S0168-8278(98)80061-5. PMID 9764990.
  20. ↑ Chavez-Tapia, Norberto C.; Barrientos-Gutierrez, Tonatiuh; Tellez-Avila, Felix I.; Soares-Weiser, Karla; Uribe, Misael (2010-09-08). "Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding". The Cochrane Database of Systematic Reviews (9): CD002907. doi:10.1002/14651858.CD002907.pub2. ISSN 1469-493X. PMID 20824832.
  21. ↑ Chavez-Tapia, NC; Soares-Weiser, K; Brezis, M; Leibovici, L (21 January 2009). "Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients". The Cochrane Database of Systematic Reviews (1): CD002232. doi:10.1002/14651858.CD002232.pub2. PMID 19160207.
  22. ↑ Hiyama, T.; Yoshihara, M.; Tanaka, S.; Haruma, K.; Chayama, K. (Apr 2009). "Effectiveness of prokinetic agents against diseases external to the gastrointestinal tract". J Gastroenterol Hepatol. 24 (4): 537–46. doi:10.1111/j.1440-1746.2009.05780.x. PMID 19220673.
  23. ↑ Sort P, Navasa M, Arroyo V, et al. (1999). "Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis". N. Engl. J. Med. 341 (6): 403–9. doi:10.1056/NEJM199908053410603. PMID 10432325.
  24. ↑ Runyon BA (1988). "Spontaneous bacterial peritonitis: an explosion of information". Hepatology. 8 (1): 171–5. doi:10.1002/hep.1840080131. PMID 3338704.
  25. ↑ CONN HO (April 1964). "Spontaneous peritonitis and bacteremia in Laennec's cirrhosis caused by enteric organisms. A relatively common but rarely recognized syndrome" (PDF). Ann. Intern. Med. 60 (4): 568–80. doi:10.7326/0003-4819-60-4-568. PMID 14138877.
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