Spontaneous

Bacterial Peritonitis
Katherine Yu
May 2014
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
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?
Diagnosis
SBP is diagnosed by an ascites cell count of 250 PMNs/mm3
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
Diagnosis
Type Ascites cell Ascites culture
count/mm3
Spontaneous bacterial 250 PMNs Usually polymicrobial.
peritonitis (SBP)
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/mm3 but with negative ascites culture.
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
Indications for Prophylaxis
Primary prophylaxis:
If ascitic fluid total protein (AFTP) < 1.5 & Na <130, Cr >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
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?
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) < 1.5 & Na <130, Cr >1.2 or Child-Pugh score B.
The treatment is daily oral norfloxacin or Bactrim DS.