Spontaneous Bacterial Peritonitis (SBP) & Ascitic Fluid Infection

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.

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.

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

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.

Risk factors for ascitic fluid infection

severity of liver disease deficient AF bactericidal activity (AF total protein <1 g/dl, and/or AF C3 <13 mg/dl)

acute GI bleeding urinary tract infection urinary catheters, IV catheters previous episode(s) of SBP

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

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

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.

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%.

Combining these results yields the following subgroups:

SBP exists when the polymorphonuclear neutrophil (PMN) count is >250 cells/mL in conjunction with a positive bacterial 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.

 Monomicrobial nonneutrocytic bacterascites exists when

a positive culture result coexists with a PMN count <250 cells/mL. Although this may often be the result of

contamination of bacterial cultures, 38% of these patients

develop SBP. Therefore, monomicrobial nonneutrocytic

bacterascites may represent an early form of SBP. For this reason, any patient suspected clinically of having SBP in this setting must be treated.

Variants of ascitic fluid infections include:

Variant of ascitic fluid (AF) infection Spontaneous bacterial peritonitis (SBP) Culture-negative neutrocytic ascites (CNNA) Secondary bacterial peritonitis* AF culture monomicrobial negative AF PMNs (per mm3) 250 250

polymicrobial

250

Monomicrobial nonneutrocytic bacterascites (MNB)

monomicrobial

< 250

Polymicrobial bacterascites**

polymicrobial

< 250

*a surgically treatable intraabdominal focus of infection exists ** a rare iatrogenic variant occurring as a result of accidental intestinal puncture during paracentesis

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 <7.35 and PMN count of >500 cells/mL was 100% sensitive and 96% specific.

Blood and urine cultures should be obtained in all patients suspected of having SBP.