Spontaneous Bacterial

Peritonitis(SBP)

Dr.Chakravarthy,P.S,MD
PG in Gastroenterology,
AMC/KGH

OVERVIEW

Definitions & Classification

Etiology & Pathophysiology
Clinical features
Investigations
Treatment
Prognosis
Prevention

CLASSIFICATION
Spontaneous asc.fluid infection
SBP
MNB
CNNA
Secondary bacterial peritonitis
Gut perforation/ non perforation

Polymicrobial bacterascites

DEFINITIONS
SBP
An infection of initially sterile ascitic fluid
without a detectable, surgically treatable
source of infection

Conn HO, 1969

 A positive ascitic fluid culture (essentially always

a monomicrobial infection) +
elevated ascitic fluid absolute PMN count (i.e.,
250 cells/mm3)
without an evident intra-abdominal source of
infection that requires surgical treatment

DEFINITIONS
MNB
a positive ascitic fluid culture for a single
organism +
an ascitic fluid PMN count lower than 250
cells/mm3 +
no evidence of an intra-abdominal surgically
treatable source of infection

DEFINITIONS
CNNA
the ascitic fluid culture grows no bacteria +
the ascitic fluid PMN count is 250 cells/mm3 or
greater +
no antibiotics have been given (not even a
single dose) +
no other explanation for an elevated ascitic
PMN count

DEFINITIONS
Secondary bacterial peritonotis
ascitic fluid culture positive (usually for multiple
organisms) +
PMN count is 250 cells/mm3 (0.25 109/L) or
greater +
an intra-abdominal surgically treatable primary
source of infection

DEFINITIONS
Polymicrobial bacterascites
Multiple organisms are seen on Gram stain or
cultured from the ascitic fluid +
PMN count is lower than 250 cells/mm3 (0.25
109/L)

Incidence
20% of all cirrhotics
50% at admission, 50% during hospital stay
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

ETIOLOGY

PATHOPHYSIOLOGY

 Spontaneous variants of ascitic fluid almost

exclusively in the setting of severe liver disease
Liver disease usually is chronic (cirrhosis), but
may be acute (fulminant hepatic failure) or
subacute (alcoholic hepatitis)

CNNA results from

Previous antibiotic treatment
Inadequate amount of fluid inoculated
Spontaneously resolving SBP after clearing of all
bacteria
Most of the spontaneous forms(upto 62%)
resolve by themselves

Risk factors
Paracentesis
GI hemorrhage,UTIs
Deficient AF bactericidal activity (AF total protein
<1 g/dl, and/or AF C3 <13 mg/dl)
Previous episode(s) of SBP

CLINICAL FEATURES

Diagnosis
High index of suspicion
Low threashold for paracentesis
Clinical deterioration
A clinical diagnosis without a paracentesis is
inadequate

Diagnostic Paracentesis
All patients with ascites admitted to hospital as well as in
cirrhotics
Signs of abdominal or systemic infection (abdominal pain
or tenderness, disturbed intestinal function, fever,
acidosis, peripheral leukocytosis)
Patients presented with encephalopathy or worsened
renal functions.
AASLD,2013 guidelines(Class 1 ,Level B evidence)

ESSENTIALS OF PARACENTESIS
Skin needle to be replaced by sterile needle
Blood culture bottles to be inoculated (atleast 10ml of
fluid)
Cell count sample to be inoculated into EDTA container
Cell count to be done manually(not on autoanalyzers)
EASL 2010 guidelines for SBP

Ascitic fluid analysis

Total count
Differential count
Absolute PMN count
Albumin
Culture and sensitivity

Ascitic fluid culture

Positive in upto 40% cases
Most commonly Gm neg.bacteria(E.coli) & Gm
positive cocci(Streptococcus)
30% GNBs resistent to quinolones & 30% to
trimethoprim-sulphamethoxazole
Low resistance to 3rd gen.cephalosporins

Ascitic fluid culture

Among culture positive samples,
2/3rd neutrocytic(SBP) &
1/3rd non-neutrocytic(MNB)
Sec.BP 0% to 20% cases
Polymicrobial 1 in 1000 samples

Ascitic fluid analysis

Total protein risk of SBP
Glucose PMN activity
(>50mg/dl in SBP, <50 in Sec.BP)
LDH 43+/- 20mU/ml(sterile fluid)
Bilirubin only for orange/brown fluid
> serum level (or) >6mg/dl viscus
perforation

 PMN > 250/Cmm + high suspicion of Sec.BP

test for asc.fluid total protein,glucose, LDH,ALP &

CEA
AASLD 2013,(Class 2A,Level B)

Leukocyte esterase (dipstick) test

Efficacy of leukocyte esterase dipstick test as a
rapid test in diagnosis of spontaneous bacterial
peritonitis.
Rerknimitr R, Rungsangmanoon W, Kongkam P, Kullavanijaya P.
Gastroenterology Unit, Department of Internal Medicine, Faculty of
Medicine, Chulalongkorn University, Bangkok
World J Gastroenterol. 2006 Nov 28;12(44):7183-7
CONCLUSION:
Dipstick test can be used as a rapid test for screening of SBP. The
higher cut off colorimetric scale has a better specificity and positive
predictive value but a lower sensitivity

Leukocyte esterase (dipstick) test

Bedside leucocyte esterase reagent strips with
spectrophotometric analysis to rapidly exclude
spontaneous bacterial peritonitis: a pilot study.

Gaya DR, David B Lyon T, Clarke J, Jamdar S, Inverarity D, Forrest EH,

John Morris A, Stanley AJ.

Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow,

UK.
Eur J Gastroenterol Hepatol. 2007 Apr;19(4):289-95

Conclusion :Bedside leucocyte esterase strips, spectrophotometrically

read, can reliably exclude spontaneous bacterial peritonitis in patients with
cirrhotic ascites. In our series, a negative strip result effectively ruled out this
important condition, and suggests that the requirement for manual
polymorphonuclear leucocyte counting in this setting could be removed

Leukocyte esterase (dipstick) test

Review article: the utility of reagent strips in the
diagnosis of infected ascites in cirrhotic patients.
Nguyen-Khac E, Cadranel JF, Thevenot T, Nousbaum JB.
Hepato-Gastroenterology, Amiens University Hospital, CHU Nord,
place Victor Pauchet, France
Aliment Pharmacol Ther. 2008 Aug 1;28(3):282-8
CONCLUSION:
Use of reagent strips for the diagnosis of SBP cannot be
recommended, in view of low sensitivity and a high risk of false
negatives, especially in patients with SBP and low
polymorphonuclear count.

Ascitic fluid Lactoferrin

Ascitic Fluid Lactoferrin for Diagnosis of
Spontaneous Bacterial Peritonitis
Mansour A. Parsi, Sherif N. Saadeh, Nizar N. Zein, Gary L. Davis

Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA

Gastroenterology,Volume 135, Issue 3 , 803-807, September 2008

Conclusions: AFLAC can serve as a sensitive and specific test for diagnosis
of SBP. Qualitative bedside assays for the measurement of AFLAC can be
developed easily and may serve as a rapid and reliable screening tool for
SBP in patients with cirrhosis

Granulocyte elastase
Rapid detection of spontaneous bacterial peritonitis by
granulocyte elastase latex immunoassay and reagent
strip.
Yamazaki M, Sano R, Kuramoto C, Yoshiji H, Uemura M, Fukui H,
Kamiya M, Okamoto Y.
Central Clinical Laboratory, Nara Medical University Hospital,
Kashihara 634-8522, Japan
Rinsho Byori. 2011 Jun;59(6):549-58
Results :The sensitivity, specificity, and positive and negative
predictive values of the reagent strips for diagnosis of SBP were
92.9%, 90.9%, 76.5%, and 97.6%, respectively.
Conclusion : GE-LIA reagent strips are rapid and sensitive and
can aid diagnosis of SBP.

 Imaging
rarely required for SBP
useful for Sec.BP

Differential diagnosis

Tuberculosis
Acute pancreatitis
Peritoneal carcinomatosis
Peritoneal hemorrhage

TREATMENT
Ideal timing to treat.
As early as possible ..if
Temperature >37.8*C(100*F)
Abdominal pain/ tenderness
Altered mental status
Start empirical i.v antibiotic (broad-spectrum)
+ supportive measures
AASLD2013,(Class 1, Level A)

Which drug to start with?

Third generation cephalosporin
(preferably cefotaxime 2gm,IV, 8th hourly)
AASLD 2013,(Class 1, Level A)

Ofloxacin 400mg 12th hourly

AASLD 2013,(Class 2A,Level B)

(exclude prior exposure to

quinolones,vomiting,shock,creat>3mg/dl, Gr.II or
more encephalopathy prior to therapy)

TREATMENT
PMN<250 + symptoms/signs of infection

should receive empiric antibiotic

(till the culture report)
AASLD 2013,(Class 1, Level B)

TREATMENT
PMN > 250/cmm + clinical picture suggestive

treat just like classical SBP (irrespective of

culture report)
EASL 2010 guidelines for SBP

TREATMENT
Albumin ..?
1.5gm/kg body wt within 6hrs of detection
&
1.0gm/kg body wt on 3rd day
(PMN>250, Creat>1mg/dl, BUN>30mg/dl ,
total bilirubin>4mg/dl)
AASLD 2013,(Class 2A, Level B)

 Albumin Infusion Improves Outcomes of

Patients With Spontaneous Bacterial Peritonitis:
A Meta-analysis of Randomized Trials.

Salerno F, Navickis RJ, Wilkes MM

Dipartimento di Medicina Interna, Universit degli Studi di Milano,
Policlinico IRCCS San Donato, Milano, Italy.
Clin Gastroenterol Hepatol. 2013 Feb;11(2):123-130
CONCLUSIONS:
In a meta-analysis of 4 RCTs (288 patients), albumin infusion
prevented renal impairment and reduced mortality among patients
with SBP

Clinical Gastroenterology and hepatology,2012,Vol.10,No.3

Repeat paracentesis
Clinical deterioration
fever, abd.pain, renal failure,altered mental
status,GI bleed,peripheral leukocytosis

Predictors of poor outcome

Age >60yr
Community Vs hospital acquired SBP
S.creatinine >3mg/dl
BUN > 30mg/dl
Child Pugh score >9

PROGNOSIS
<5% mortality (48-95% in the past)
Mortality in cured pts is d/t worsening of
underlying liver disease/ GI bleeding
100% mortality in Sec.BP without surgery
50% mortality with laparotomy

PREVENTION
IV Ceftriaxone/oral Norfloxacin BD for 7days in
all GI beeds with cirrhosis (Class 1,Level A)
Daily norfloxacin (longterm) in survivors of SBP
(Class 1,Level A)

AASLD 2013

 Cirrhosis & ascites but no GI bleed

longterm Norfloxacin indicated if asc.fluid total
protein < 1.5gm/dl & one of the following present
- S.creatinine >/= 1.2mg/dl
- BUN >/= 25mg/dl
- S.Na+ </= 130meq/L
- CTP score >/= 9
AASLD 2013 (Class1 ,Level B)

 Primary Prophylaxis of Spontaneous Bacterial

Peritonitis Delays Hepatorenal Syndrome and
Improves Survival in Cirrhosis
Javier Fernndez, Miquel Navasa
Gastroenterology, Volume 133, Issue 3, September 2007, Pages
818-824

Take Home message

Infection of asc.fluid is often underdiagnosed
All admitted pts should undergo diagnostic
paracentesis
Meticulous care required while processing the
samples
Try to ruleout secondary causes in all possible
cases
Rapid bedside tests help in changing outcome

Take Home message

Early antibiotic therapy grossly alters the
final outcome
Primary prophylaxis has a role in
preventing systemic complications and
improving survival

REFERENCES

Sleisenger text book of GI and liver diseases,9th edition

Schiffs diseases of the liver,11th edition
AASLD guidelines for ascites & SBP(2013)
EASL guidelines for ascites and SBP(2010)
Cochrane metaanalysis database for SBP treatment
Jour of clin gastroenterology and hepatology,Feb.2013
Gastroenterology,vol.133,Sept,2008
Aliment Pharmacol Ther. 2008 Aug