Spontaneous Bacterial Peritonitis

Pt with h/o cirrhosis, ascites presents with abdominal fullness, malaise. Reports fever, abdominal pain, confusion. Fever, hypotension, altered mental status, gynecomastia, abdominal tenderness, hepatomegaly on exam.

• Obtain CBC, CMP, GGT, PT, PTT, INR

• Abdominal U/S performed prior to antibiotic administration shows ascites

  • Ascitic fluid sent for differential leukocyte count, total protein level, a serum-ascites albumin gradient, fluid cultures

  • Ascitic fluid neutrophil count > 250/mL: Start empiric cefotaxime 2g q8h

• Treatment after starting empiric antibiotics

  • Concern for hepatorenal syndrome: Continue to monitor

  • Administer albumin 1.5g/kg within 6 hours of diagnosis and 1g/kg on day 3

  • Discharge with prophylactic Bactrim SS (400mg SMX + 80mg TMP) daily

• Patient counseling

  • Abstain from alcohol

  • Long-term therapy may involve liver transplant

Notes

• Bactrim or norfloxacin ppx recommended for patients who survive episode of SBP

• Ascitic fluid neutrophil count > 250/mL is diagnostic of SBP and an indication for starting empiric antibiotics