Treatment of Spontaneous Bacterial Peritonitis

Abstract

Spontaneous bacterial peritonitis (SBP) is an infection of patients with cirrhosis and ascites. This peculiarity is due to the frequent intestinal translocation that allows bacteria to cross the intestinal barrier, colonizing the ascitic fluid. In cirrhosis, SBP is inferior only to urinary tract infections. It is prevalently sustained by Gram-negative bacteria such as Escherichia coli and Klebsiella. Risk factors for developing SBP are advanced age, refractory ascites, variceal bleeding, renal failure, low albumin levels (below 2.5 g/ml), bilirubin over 4 mg/dl, Child-Pugh class C and a previous diagnosis of SBP. Thus, this is an indication for a long-term antibiotic prophylaxis with norfloxacin. Renal failure - especially the hepatorenal syndrome - complicates SBP in about 20% of cases independently of the efficacy of the antibiotic therapy. The mortality of these patients is about 90%. Infusion of albumin significantly reduces the incidence of hepatorenal syndrome and consequently the risk of death. Long-term quinolonic prophylaxis as well as increased antibiotic therapies are causing the emergence of multidrug-resistant agents as frequent causes of SBP. In such cases, the antibiotic sensitivity to quinolones is low, and European recommendations suggest a second-line antibiotic therapy, including meropenem or piperacillin plus tazobactam. Collection of blood, urine and ascitic fluid for cultures is important for bacterial recognition, possibly before starting an empirical antibiotic therapy. Indeed, the probability of positive cultures rapidly vanishes when they are performed during already implemented antibiotic administration. It is important to know that a failure of the first-line therapy is associated with an increased probability of death.

Efficacy of vasopressin V2 receptor antagonist tolvaptan in treatment of hepatic edema

“…Thus, CRP, BUN, and Na (as shown in Table b) are considered to reflect the exacerbation of liver cirrhosis or HCC, and associated complicating conditions such as SBP or hepatorenal syndrome . It may be important to adequately investigate the influence of advanced hepatic condition on the therapeutic effect of tolvaptan …”

“…41 It may be important to adequately investigate the influence of advanced hepatic condition on the therapeutic effect of tolvaptan. [42][43][44][45][46][47] The long-term response rate on day 90 was 47% (70/ 150 patients), and hepatic condition and initial response rate were identified as predictive factors for long-term response to tolvaptan. The long-term response rate in the good hepatic condition group was as high as 62%, whereas that in the poor hepatic condition group was extremely low (39%).…”

Acid suppression therapy and its association with spontaneous bacterial peritonitis incidence: A systemic review and meta‐analysis

“…Fourth, among our enrolled studies, 14 out of 20 articles excluded LC patients with acute upper gastrointestinal bleeding (data not shown). In our opinion, patients with acute gastrointestinal bleeding might predispose to SBP to some extent . Actually, PPI is widely used in patients with gastroesophageal variceal bleeding, even though the indication of PPI administration during varices hemorrhage remains unclear.…”

“…In our opinion, patients with acute gastrointestinal bleeding might predispose to SBP to some extent. 56 Actually, PPI is widely used in patients with gastroesophageal variceal bleeding, even though the indication of PPI administration during varices hemorrhage remains unclear. Lo et al 57 documented in a meta-analysis supporting the evidence that short-term use of PPI (10 days) can reduce ulcer size after endoscopic variceal ligation.…”

Manejo Da Peritonite Bacteriana Espontânea Na Emergência

“…Além dos já citados, alguns outros fatores que podem ser relacionados ao aumento do risco de desenvolvimento da PBE, porém de forma menos compreendida, são a idade avançada, ascite refratária, manejo endoscópico de varizes esofagianas, uso de inibidores de bomba de prótons e um diagnóstico prévio de PBE (SALERNO & LA MURA, 2015). O aumento da permeabilidade da mucosa intestinal é um importante fator que corrobora para a translocação de bactérias do lúmen intestinal para os linfonodos mesentéricos.…”