Spontaneous bacterial peritonitis ( SBP ) in adults - Diagnosis and management of
|Last review: 19/09/2017|
|Next review: 07/12/2019|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
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
Spontaneous bacterial peritonitis ( SBP ) in adults
SBP may be suspected on clinical grounds but confirmation and classification is a laboratory diagnosis.
A routine diagnostic paracentesis should be performed PRIOR to starting antimicrobial therapy within 6 hours in all patients:
If genuine penicillin allergy –Teicoplanin IV (see dosing guideline. Off-label use and the patient should be informed of this) plus Aztreonam 1g 8-hourly iv OR Tigecycline 100mg loading followed by 50mg 12-hourly*. *Child Pugh C liver disease reduce to 25mg 12-hourly iv.
For directed therapy regimens, duration of treatment, switch to oral agent(s) see full guideline
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).
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 (Stassen et al., 1986). An ascitic fluid neutrophil count ≥ 250/mm3 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 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]
The yield of ascitic fluid culture can be increased from ~45% to more than 80% by inoculating ascitic fluid samples into blood culture bottles (Bobadilla et al., 1989). At least 10ml of fluid is required.
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]
|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 4.5g 8-hourly iv. [Evidence level D]
If genuine penicillin allergy –Teicoplanin IV (see dosing guideline. Off-label use and the patient should be informed of this) plus Aztreonam 1g 8-hourly iv OR Tigecycline 100mg iv loading followed by 50mg 12-hourly iv*. [Evidence level D]
*Tigecycline requires dosage adjustment in Child Pugh C liver disease to 25mg 12-hourly iv.
Up to 10% of infections are caused by Gram-positive cocci (particularly Enterococcus species). Ampicillin-Tobramycin and Co-amoxiclav have been used with the assumption that they would provide adequate Gram-positive cover.
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.
The final recommendations were influenced by local epidemiology and resistance patterns which are shown in Figures 1 and 2.
Piperacillin/tazobactam was chosen in order to provide appropriate antimicrobial cover (including enterococci, streptococci, and resistant gram-negative including Pseudomonas species) and to avoid the use of cephalosporins, quinolones (whose activity can no longer be relied upon for empirical treatment) and Gentamicin (to reduce the risk of toxicity). Teicoplanin and Aztreonam in combination provides a similar spectrum of activity. Tigecycline has an appropriate spectrum of activity (active against Staphylococus aureus, enterococci and many Gram negatives but not Pseudomonas). Tigecycline is licensed for use in intrabdominal infections but data specific for spontaneous bacterial peritonitis are lacking.
N.B. Co-amoxiclav susceptibility was not been routinely tested in the laboratory during the review period so data are not available. Cefuroxime can be used as a reasonable marker of Co-amoxiclav susceptibility. This antimicrobial is less broad spectrum than Piperacillin/tazobactam against Gram-negatives and lacks antipseudomonal activity.
|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 /Ofloxacin , Co-amoxiclav , and oral 3rd generation cephalosporins demonstrated non-inferiority when compared to iv therapies. Oral Ofloxacin was compared with iv Cefotaxime in 123 patient with uncomplicated SBP (no encephalopathy, renal failure, vomiting, ileus, shock or GI haemorrhage) - no difference in the number of deaths, resolution of SBP or presence of adverse effects was seen. Two 3rd generation cephalosporins were compared in 38 patients - oral cefixime vs iv ceftriaxone, but no significant differences were found for any of the outcomes provided. No difference in effectiveness or mortality was demonstrated when oral Ciprofloxacin was compared to iv Ciprofloxacin in 80 cirrhotic patients with SBP.
Recommendation: Switch to oral antimicrobials should be considered when patients are clinically improving, afebrile and inflammatory markers falling. [Evidence level C]
|Please contact microbiology if the patient is not responding to the recommended antimicrobial regimens.|
|Target patient group:||all adult patients with SBP|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
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