Spontaneous bacterial peritonitis in cirrhosis

Abstract

Spontaneous bacterial peritonitis is a common complication of cirrhosis with high risk of deathBacterial infection of ascites fluid, most commonly from Escherichia coli or Klebsiella pneumoniae, causes the condition. 1 Its prevalence in patients with cirrhosis is 10.8% in North America, and nearly 25% of patients die despite appropriate antibiotic treatment. 2 2 The presentation varies and patients may not have abdominal pain or fever Spontaneous bacterial peritonitis is often a trigger for cirrhotic decompensation, which can manifest as isolated hepatic encephalopathy, gastro intestinal bleeding, renal failure, increasing ascites volume or any vital sign abnormalities, including hypothermia. 1,3 Given its highly variable presentation, the current guideline recommends that every patient who presents urgently to hospital with cirrhosis and ascites be tested for the condition. 1 3 Prompt diagnosis is required to reduce risk of death A paracentesis that shows ascites fluid with a polymorphonuclear leukocyte count of 250 cells/mm 3 (0.25 × 10 9 /L) or greater confirms the diagnosis. In 1 study, delaying paracentesis by 12 hours resulted in a 2.7-fold increase in odds of death. Clinicians should perform paracentesis as soon as possible. 4 Empiric antibiotic treatment requires consideration of local resistance patternsIn North America, antibiotic resistance in spontaneous bacterial peritonitis is 17.8%, with methicillin-resistant Staphylococcus aureus the most common resistant organism. 2 Empiric treatment in low-resistance areas is a third-generation cephalosporin, and in high-resistance areas is piperacillin-tazobactam. 1 5 Clinicians should prescribe albumin within 6 hours of diagnosis to confer a mortality benefit Albumin has a number needed to treat of 6 patients to prevent 1 death, and of 4 patients to prevent 1 case of renal failure, if given within 6 hours of diagnosis of spontanous bacterial peritonitis. 5 The latest guideline recommends that, in addition to fluid resuscitation, albumin be given to all patients with the condition. 1 Recommended dosing is albumin 1.5 g/kg on day 1 and 1 g/kg on day 3. 1