Spontaneous bacterial peritonitis
(SBP; see “Ascites”; Hepatology 2021;74:1014)
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High mortality rate; risk factors include ascitic TP <1 g/dL, hx of SBP, current GIB
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Can p/w
- encephalopathy,
- abd pain,
- fever,
- but often (25%) asx; perform diagnostic paracentesis in all hospitalized patients with cirrhosis and ascites
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Micro:
- typically, monobacterial GNRs (E. coli, Klebs) >GPCs (S. pneumo, enterococcus)
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Rx:
- 3rd-gen. ceph is → 1st line;
- consider pip/tazo or mero if ↑ risk of MDRO;
- vanc if prior MRSA ⊕;
- IV albumin 1.5 g/kg at ↣ time of dx & 1 g/kg on day 3 → ↑ survival (NEJM 1999;341:403)
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Repeat paracentesis at ↣ 48 h:
- expect 25% ↓ in PMNs if Rx working.
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Indefinite Ppx if (1) h/o SBP or (2) ascitic TP <1.5 plus: Na ≤130 or Cr ≥1.2 or BUN ≥25 or [CPS ≥9 + Tbili ≥3] (Am J Gastro 2009;4:993) → cipro 500 mg qd or Bactrim DS qd. Short-term Ppx: CTX 1 g IV × 7d if GIB (Δ to cipro 500 bid/Bactrim DS bid when eating).