Spontaneous bacterial peritonitis ( SBP ) in adults - Diagnosis and management of |
Publication: 23/12/2009 |
Next review: 25/10/2022 |
Clinical Guideline |
UNDER REVIEW |
ID: 1763 |
Approved By: Improving Antimicrobial Prescribing Group |
Copyright© Leeds Teaching Hospitals NHS Trust 2019 |
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated. |
Update on aztreonam injection shortage - now only restricted outside of CF and UTI (protected antibiotic codes no longer required for these indications). See alternatives - 22 August 2018
Guideline for diagnosis and management of spontaneous bacterial peritonitis (SBP) in adults
Summary Spontaneous bacterial peritonitis ( SBP ) in adults |
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Diagnosis
Examination.
SBP may be suspected on clinical grounds but confirmation and classification is a laboratory diagnosis.
Table 1. Ascitic fluid tests required.
Non-antimicrobial management
Antimicrobial treatment
If genuine penicillin allergy –Tigecycline IV
For directed therapy regimens, duration of treatment, switch to oral agent(s) see full guideline |
Clinical Diagnosis | ||||||||||||||||||||||||||||||
History Examination.
Table 3. Adapted from Sleisenger’s & Fordtran’s Gastrointestinal & Liver Disease, 7th Ed, Elsevier. Many of the features of liver failure make the recognition of sepsis difficult. For example, the reduced peripheral neutrophil count due to hypersplenism, elevated basal heart rate and relative hypotension due to the hyperdynamic circulation and basal hyperventilation due to encephalopathy (Wong et al., 2005). A high index of suspicion must be maintained. [Evidence level C] SBP may be suspected on clinical grounds but confirmation and classification is a laboratory diagnosis (see investigations below). |
Investigation |
SBP can only be diagnosed by examining a sample of ascitic fluid. Abdominal paracentesis (ascitic tap) is safe (Runyon 1986, Lin et al., 2005). Recommendation: A routine diagnostic paracentesis should be performed PRIOR to starting antimicrobial therapy within 6 hours in all patients:
A number of ascitic fluid parameters have been evaluated for the diagnosis of SBP. The highest accuracy for a diagnosis of SBP can be made from a pH ≤ 7.34 or a blood-ascitic fluid gradient ≥ 0.10 in combination with an ascitic fluid neutrophil count > 500/mm3 (0.5 x 109/l) (Stassen et al., 1986). An ascitic fluid neutrophil count ≥ 250/mm3 (0.25 x109/l) is consistent with a diagnosis of SBP (Garcia-Tsao 1992, Arroyo et al., 2000). The total white cell count can also be used to diagnose SBP. Runyon et al. (2006) suggest a WCC > 500mm3 (0.5 x 109/l) is diagnostic, irrespective of the differential. The ascitic cell count and differential is performed by automated techniques in the laboratory. Recommendation: Samples of ascitic fluid should be routinely sent to haematology for a differential white cell count [Evidence level B]. Recommendation: an ascitic fluid neutrophil count ≥ 250/mm3 (or 0.25 x109/l) should be considered diagnostic for SBP in an appropriate clinical situation. [Evidence level B] Leukocyte esterase reagent strips have a high sensitivity (64 to 100%) and specificity (92.5 to 100%) in the detection of an elevated ascitic fluid neutrophil count (Castelote et al., 2002, Sapey et al., 2005). Although these are cheap, rapid and readily available on wards (urine dipsticks) microscopy is an absolute requirement so bedside testing will not alter management and is not therefore recommended. Recommendation: use of Leukocyte esterase reagent strips is not recommended for the diagnosis of SBP. [Evidence level D] Recommendation: 10ml ascitic fluid should be inoculated directly into both an aerobic and anaerobic blood culture bottle according to Standard operating procedure. [Evidence level D] Recommendation: When an ascitic culture unexpectedly yields an organism known to cause SBP in a patient without clinical signs of infection or with a low ascitic WCC the ascitic tap must be repeated to reassess the neutrophil count and re-culture (Rimola et al., 2000). [Evidence level C] Recommendation: When an ascitic culture yield a potential contaminant (e.g. coagulase-negative staphylococcus or “diphtheroid” the ascitic tap should be repeated to reassess the neutrophil count and re-culture (Rimola et al., 2000). [Evidence level C] Recommendation: If mixed organisms are seen on Gram-stain or cultured – (particularly anaerobes and Candida species). Consider a surgical cause or sampling from gut lumen. [Evidence level C] Recommendation: consider secondary bacterial peritonitis if ascitic fluid neutrophil count is climbing despite 48 hours of antibiotics. [Evidence level C] Paracentesis may be repeated after 48 hours of treatment to assess the response to antibiotics. [Evidence level D] |
Treatment |
Non-Antimicrobial Treatment |
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Empirical Antimicrobial Treatment |
The initial decision to treat suspected ascitic fluid infection is based on an elevated fluid neutrophil count and/or the clinical setting. A high index of suspicion is essential. CNNA and SBP have comparable mortality rates so similar management is warranted. The recommended empirical regimen for SBP is Piperacillin/tazobactam If genuine penicillin allergy –Tigecycline IV Note: Tigecycline is not active against Pseudomonas species; call Microbiology if there are any concerns about this. Up to 10% of infections are caused by Gram-positive cocci (particularly Enterococcus species). Ampicillin-Tobramycin The Cochrane review made no firm conclusions from the randomised controlled trials. Although third generation cephalosporins have been established as the standard treatment of SBP in many centres, current concerns about Clostridium difficile infection, selection of extended-spectrum beta-lactamase (ESBL) producing coliforms and adequacy of spectrum have raised questions about the wisdom of this approach. Piperacillin/tazobactam N.B. Co-Amoxiclav (Amoxicillin-Clavulanate) |
Directed Antimicrobial Treatment (when microbiology results are known) |
If ascitic fluid culture results are positive then antimicrobials should be changed to optimise effectiveness and reduce adverse effects - this will usually be the most narrow spectrum effective agent available. Directed therapy should be determined on a case by case basis with discussion with Microbiology if required. |
Duration of Treatment |
In most studies the length of treatment was based on disappearance of symptoms and signs. One study demonstrated no difference in either mortality or resolution of SBP with 5 or 10 days treatment with intravenous Cefotaxime Recommendation: To reduce adverse events including selection for resistant bacteria five days should be the standard duration, extended up to 10 days if clinical response is slow. [Evidence level B] |
Switch to oral agent(s) |
There is some evidence to support a switch from intravenous to oral antibiotics early in patients who show an improvement after a short IV course. Oral therapy alone may be possible from the start of treatment in those without systemic inflammatory response or renal failure. Oral Ciprofloxacin Recommendation: Switch to oral antimicrobials should be considered when patients are clinically improving, afebrile and inflammatory markers falling. [Evidence level C] If patients have been commenced on Piperacillin/tazobactam |
Treatment Failure |
Please contact Microbiology if the patient is not responding to the recommended antimicrobial regimens. |
Provenance
Record: | 1763 |
Objective: | Aims
Objectives
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Clinical condition: | SBP |
Target patient group: | all adult patients with SBP |
Target professional group(s): | Secondary Care Doctors Secondary Care Nurses Pharmacists |
Adapted from: |
Evidence base
References
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Approved By
Improving Antimicrobial Prescribing Group
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