Spontaneous Bacterial Peritonitis (SBP) & Ascitic
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Transcript of Spontaneous Bacterial Peritonitis (SBP) & Ascitic
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Spontaneous Bacterial
Peritonitis (SBP) & Ascitic FluidInfection
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Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection of
ascitic fluid.
Patients with cirrhosis and ascites carry a 10% annual risk of ascitic fluid
infection.
Of patients with cirrhosis who have SBP, 70% are Child-Pugh class C. In
these patients, the development of SBP is associated with a poor long-term
prognosis.
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Pathophysiology
Bacterial seeding of ascitic fluid is the principle of ascitic fluid
infection. The most two likely roots are translocation and
hematogenous spread
In cirrhotic patients, bacterial translocation was significantly
increased only in Child C patients (30%) compared with 8% in Child
B and 3% in Child A patients. In fact, the only independent
predictor of translocation was Child-Pugh class.
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Predisposing factor may be :
Intestinal bacterial overgrowth (attributed to decreased intestinal
transit time)
Impaired phagocytic function
Low serum and ascites complement levels
Decreased activity of the reticuloendothelial system
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Etiologic agents (>90% intestinal flora)
Three forth of infections are due to aerobic gram-negative
organisms (50% of these being Escherichia coli )
One fourth are due to aerobic gram-positive organisms
(19% streptococcal species). However, recent data suggest the
percentage of gram-positive infections may be increasing due to
quinolone resistance among gram-positive bacteria.
Anaerobic organisms are rare (1%) because of the high
oxygen tension of ascitic fluid.
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Risk factors for ascitic fluid infection
severity of liver disease
deficient AF bactericidal activity (AF total protein
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Clinical presentation and diagnosis of ascitic fluid infection
A broad range of symptoms and signs are seen in SBP. A high index
of suspicion must be maintained when caring for patients with
ascites, particularly those with acute clinical deterioration.Completely asymptomatic cases in as many as 30% of patients.
Fever and chills occur in as many as 80% of patients.
Abdominal pain or discomfort is found in 70% of patients.
Worsening or unexplained encephalopathy
Diarrhea
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Ascites that does not improve following administration of diuretic
medication
Worsening or new-onset renal failure
Ileus
Abdominal tenderness (50%) .
Hypotension (5-14%)
Signs of hepatic failure such as jaundice and angiomata
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Diagnostic paracentesis and direct inoculation of routine blood
culture bottles at the bedside with 10 mL of ascitic fluid must be
performed. The results of aerobic and anaerobic bacterial
cultures , used in conjunction with the cell count , prove the most
useful in guiding therapy for those with SBP.
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An ascitic fluid neutrophil count of >500 cells/mL is the single
best predictor of SBP, with a sensitivity of 86% and specificity of
98%. Lowering the ascitic fluid neutrophil count to >250
cells/mL results in an increased sensitivity of 93% but a lower
specificity of 94%.
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Combining these results yields the following subgroups:
SBP exists when the polymorphonuclear neutrophil (PMN)
count is >250 cells/mL in conjunction with a positivebacterial culture result.
Culture-negative neutrocytic ascites (probable SBP)
exists when the ascitic fluid culture results are negative, but
the PMN count is >250 cells/mL. It may be the result of poor
culturing techniques or late-stage resolving infection.
Nonetheless, these patients should be treated just as
aggressively as those with positive culture results.
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Variants of ascitic fluid infectionsinclude:
AF PMNs (per mm 3)AF cultureVariant of ascitic fluid (AF) infection
250monomicrobialSpontaneous bacterial peritonitis (SBP)
250negativeCulture-negative neutrocytic ascites(CNNA)
250 polymicrobialSecondary bacterial peritonitis*
< 250monomicrobialMonomicrobial nonneutrocytic bacterascites (MNB)
< 250 polymicrobialPolymicrobial bacterascites**
*a surgically treatable intraabdominal focus of infection exists
** a rare
iatrogenic
variant occurring as a result of accidental intestinalpuncture during paracentesis
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Other studies of ascitic fluid to be considered
Cytology
Lactate : An ascites lactate level of >25 mg/dL was found to be
100% sensitive and specific in predicting active SBP in a
retrospective analysis.
pH: In the same study, the combination of an ascites fluid pH of
500 cells/mL was 100% sensitive and
96% specific.
Blood and urine cultures should be obtained in all patients
suspected of having SBP.
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