Intern Report – 4/5 SBP

Teaching Points:

  • Diagnosed with positive ascitic cultures and/or ascitic PMN count >250
  • Occurs in the setting of patients having ascites.
    • If patient does not have ascites, VERY unlikely to have SBP.
    • Only few documented cased were noted in children who had SBP without ascites. Not seen in adults.
  • Common infectious etiologies include gram negatives (e. coli, klebsiella) but can also include gram positives such as strep
  • Clinically presents with abdominal discomfort, distension, fevers, and acute encephalopathy.
  • Empiric treatment includes the following:
    • 3rd generation cephalosporin for 5 days
      • cefotaxime
      • ceftriaxone (2g IV q12 for those with normal renal function)
    • Albumin
      • 1.5g/kg on Day 1
      • 1.0g/kg on Day 3
  • Important to distinguish between spontaneous bacterial peritonitis and secondary bacterial peritonitis
    • Degree of PMN elevation
    • Presence and risk of surgically treatable infections
  • SBP Prophylaxis
    • History of SBP
      • Patients should be on lifelong prophylaxis (fluoroquinolones or Bactrim)
    • Cirrhosis with GI bleed
      • Patients should be on ceftriaxone until bleed is stable, then can transition to flouroquinolone. Total antibiotic treatment of 7 days
    • Ascitic total protein <1g/dl
      • If hospitalized, even for non-cirrhotic complication, patient should receive fluoroquinolone during inpatient stay.
  • Albumin Challenges
    • Spontaneous bacterial peritonitis
      • Very high risk for developing HRS
      • 1.5g/kg on Day 1, 1.0g/kg on Day 3
    • AKI – distinguish between HRS vs pre-renal hypovolemia
      • Albumin fluid challenge on Days 1 and 2
      • 1g/kg on both days; max dose of 100g
      • If renal function improves, suggestive of pre-renal hypovolemia. If renal function worsens, suggestive of HRS
    • Large Volume Paracentesis (>4L)
      • Give 6-8 grams albumin per liter removed

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