Address of Corresponding Author

Dig Dis 2005;23:39-46 (DOI: 10.1159/000084724)

  Key Words

• Spontaneous bacterial peritonitis
• Ascites
• Cirrhosis
• Bacterascites
• Paracentesis
• Infection

  Abstract

Spontaneous bacterial peritonitis (SBP) is a bacterial infection of ascitic fluid in patients with decompensated cirrhosis. The modifier 'spontaneous' distinguishes this from surgical peritonitis. The infecting organisms are usually enteric gram-negatives which have translocated from the bowel. Symptoms of infection occur in most patients with SBP, including fever, abdominal pain, mental status changes, and ileus. A high index of suspicion should exist for SBP in patients with cirrhosis and ascites. Diagnostic abdominal paracentesis can be undertaken with minimal risk and should be performed in all patients admitted to the hospital, during times of worsening clinical appearance, or when gastrointestinal bleeding occurs. The ascitic fluid polymorphonuclear cell count is the most sensitive test in evaluating for infection. Cultures of the ascitic fluid are helpful in identifying the organism and are best performed by bedside injection of blood culture bottles. Ascites total protein, lactate dehydrogenase, and glucose levels can assist in distinguishing SBP from secondary peritonitis. Empirical therapy is recommended after paracentesis if suspicion for infection exists. Cefotaxime is the best-studied antibiotic for this purpose and has excellent penetration into ascites with no nephrotoxicity. Prophylaxis should be limited to high-risk settings. Mortality rates in SBP have declined dramatically, largely due to earlier detection and improved therapy.

Copyright © 2005 S. Karger AG, Basel

  References

1.

Hoefs JC, Runyon BA: Spontaneous bacterial peritonitis. Dis Mon 1985;31:1-48.

2.

Conn HO: Spontaneous peritonitis and bac-teremia in Laennec's cirrhosis caused by enteric organisms: A relatively common but rarely recognized syndrome. Ann Intern Med 1964;60:568-580.

3.

Kerr DN, Pearson DT, Read AE: Infection of ascitic fluid in patients with hepatic cirrhosis. Gut 1963;4:394-398.

4.

Evans LT, Kim WR, Poterucha JJ, Kamath PS: Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites. Hepatology 2003;37:897-901.

5.

Rimola A, Garcia-Tsao G, Navasa M, Piddock LJ, Planas R, Bernard B, Inadomi JM: Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: A consensus document. J Hepatol 2000;32:142-153.

6.

Caly WR, Strauss E: A prospective study of bacterial infections in patients with cirrhosis. J Hepatol 1993;18:353-358.

7.

Runyon BA: Ascites and spontaneous bacterial peritonitis; in Feldman M, Friedman LS, Sleisenger MH (eds): Gastrointestinal and liver disease: Pathophysiology/diagnosis/management, ed 7. Philadelphia, Saunders, 2002, pp 1517-1542.

8.

Runyon BA: Spontaneous bacterial peritonitis associated with cardiac ascites. Am J Gastroenterol 1984;79:796.

9.

Kato A, Ohtake T, Furuya R, Nakajima T, Ohura M, Kumagai H, Kimura M, Hishida A, Kaneko E: Spontaneous bacterial peritonitis in an adult patient with nephritic syndrome. Intern Med 1993;32:719-721.

10.

Dhiman RK, Makharia GK, Jain S, Chawla Y: Ascites and spontaneous bacterial peritonitis in fulminant hepatic failure. Am J Gastroenterol 2000;95:233-238.

11.

Thomas FB, Fromkes JJ: Spontaneous bacterial peritonitis associated with acute viral hepatitis. J Clin Gastroenterol1982;4:259-262.

12.

Kurtz RC, Bronzo RL: Does spontaneous bacterial peritonitis occur in malignant ascites? Am J Gastroenterol 1982;77:146-148.

13.

Such J, Runyon BA: Spontaneous bacterial peritonitis. Clin Infect Dis 1998;27:669-676.

14.

Runyon BA, Hoefs JC, Canawati HN: Polymicrobial bacterascites: A unique entity in the spectrum of infected ascitic fluid. Arch Intern Med 1986;146:2173-2175.

15.

Grabau, CM, Crago SF, Hoff LK, Simon JA, Melton CA, Ott BJ, Kamath PS: Performance standards for therapeutic abdominal paracentesis. Hepatology 2004;40:484-488.

16.

Correia JP, Conn HO: Spontaneous bacterial peritonitis in cirrhosis: Endemic or epidemic? Med Clin N Am 1975;59:963-981.

17.

Runyon BA, Canawati HN, Akriviadis EA: Optimization of ascitic fluid culture technique. Gastroenterology 1988;95:1351-1355.

18.

Guarner C, Runyon BA, Young S, Heck M, Sheikh MY: Intestinal bacterial overgrowth and bacterial translocation in cirrhotic rats with ascites. J Hepatol 1997;26:1372-1378.

19.

Runyon BA, Squier S, Borzio M: Translocation of gut bacteria in rats with cirrhosis to mesenteric lymph nodes partially explains the pathogenesis of spontaneous bacterial peritonitis. J Hepatol 1994;21:792-796.

20.

Steffen EK, Berg RD, Deitch EA: Comparison of translocation rates of various indigenous bacteria from the gastrointestinal tract to the mesenteric lymph node. J Infect Dis 1988;157:1032-1038.

21.

Runyon BA, Antillon MR, Akriviadis EA, McHutchison JG: Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis. J Clin Microbiol 1990;28:2811-2812.

22.

Runyon BA: Approach to the patient with ascites; in Yamada T, Alpers DH, Laine L, Owyang C, Powell DW (eds): Textbook of Gastroenterology, ed 3. Philadelphia, Lippincott, Williams & Wilkins, 1999, pp 966-991.

23.

Rimola A, Soto R, Bory F, Arroyo V, Piera C, Rodes J: Reticuloendothelial system phagocytic activity in cirrhosis and its relation to bacterial infections and prognosis. Hepatology 1984;4:53-58.

24.

Such J, Frances R, Munoz C, Zapater P, Casellas JA, Cifuentes A, Rodriguez-Valera F, Pascual S, Sola-Vera J, Carnicer F, Uceda F, Palazon JM, Perez-Mateo M: Detection and identification of bacterial DNA in patients with cirrhosis and culture-negative, nonneutrocytic ascites. Hepatology 2002;36:135-141.

25.

Runyon BA, Morrissey RL, Hoefs JC, Wyle FA: Opsonic activity of human ascitic fluid: A potentially important protective mechanism against spontaneous bacterial peritonitis. Hepatology 1985;5:634-637.

26.

Runyon BA: Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis. Gastroenterology 1986;91:1343-1346.

27.

Woolf GM, Runyon BA: Spontaneous salmonella infection of high-protein non-cirrhotic ascites. J Clin Gastroenterol 1990;12:430-432.

28.

Runyon BA: Early events in spontaneous bacterial peritonitis (comment). Gut 2004;53:782-784.

29.

Fiuza C, Salcedo M, Clemente G, Tellado JM: Granulocyte colony-stimulating factor improves deficient in vitro neutrophil transendothelial migration in patients with advanced liver disease. Clin Diagn Lab Immunol 2002;9:433-439.

30.

DeFernandez MA, Clark A, Triger DR: Neutrophil phagocytic and bacterial function in primary biliary cirrhosis and other chronic liver diseases. Clin Exp Immunol 1987;67:655-661.

31.

Rimola A, Bory F, Teres J, Perez-Ayuso RM, Arroyo V, Rodes J: Oral, nonabsorbable antibiotics prevent infection in cirrhotics with gastrointestinal hemorrhage. Hepatology 1985;5:463-467.

32.

Soriano G, Guarner C, Tomas A, Villanueva C, Torras X, Gonzalez D, Sainz S, Anguera A, Cusso X, Balanzo J, Vilardell F: Norfloxacin prevents bacterial infection in cirrhotics with gastrointestinal hemorrhage. Gastroenterology 1992;103:1267-1272.

33.

Pardy BJ, Spencer RC, Dudley HA: Hepatic reticuloendothelial protection against bacter-emia in experimental hemorrhagic shock. Surgery 1977;81:193-197.

34.

Gines P, Rimola A, Planas R, Vargas V, Marco F, Almena M, Forne M, Miranda ML, Llach J, Salmeron JM, Esteve M, Marques JM, Jimenez de Anta MT, Arroyo V, Rodes J: Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: Results of a double-blind, placebo-controlled trial. Hepatology 1990;12:716-724.

35.

Runyon BA: Paracentesis of ascitic fluid: A safe procedure. Arch Intern Med 1986;146:2259-2261.

36.

Guarner C, Soriano G: Spontaneous bacterial peritonitis. Semin Liver Dis 1997;17:203-217.

37.

Carey WD, Boayke A, Leatherman J: Spontaneous bacterial peritonitis: Clinical and laboratory features with reference to hospital-acquired cases. Am J Gastroenterol 1986;81:1156-1161.

38.

Toledo C, Salmeron J, Rimola A, Navasa M, Arroyo V, Llach J, Gines A, Gines P, Rodes J: Spontaneous bacterial peritonitis in cirrhosis: Predictive factors of infection resolution and survival in patients treated with cefotaxime. Hepatology 1993;17:251-257.

39.

Runyon BA: Monomicrobial nonneutrocytic bacterascites: A variant of spontaneous bacterial peritonitis. Hepatology 1990;12:710-715.

40.

Runyon BA, Hoefs JC: Culture-negative neutrocytic ascites: A variant of spontaneous bacterial peritonitis. Hepatology 1984;4:1209-1211.

41.

Pelletier G, Lesur G, Ink O, Hagege H, Attali P, Buffet C, Etienne J: Asymptomatic bacterascites: Is it spontaneous bacterial peritonitis? Hepatology 1991;14:112-115.

42.

Follo A, Llovet JM, Navasa M, Planas R, Forns X, Francitorra A, Rimola A, Gassull MA, Arroyo V, Rodes J: Renal impairment after spontaneous bacterial peritonitis in cirrhosis: Incidence, clinical course, predictive factors and prognosis. Hepatology 1994;20:1495-1501.

43.

Akriviadis EA, Runyon BA: Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology 1990;98:127-133.

44.

Runyon BA: Management of adult patients with ascites due to cirrhosis. Hepatology 2004;39:841-856.

45.

Runyon BA, Antillon MR: Ascitic fluid pH and lactate: Insensitive and nonspecific tests in detecting ascitic fluid infection. Hepatology 1991;13:929-935.

46.

Antillon MR, Runyon BA: Effect of marked peripheral leukocytes on the leukocyte count in ascites. Arch Intern Med 1991;151:509-510.

47.

Castellote J, Lopez C, Gornals J, Tremosa G, Farina ER, Baliellas C, Domingo A, Xiol X: Rapid diagnosis of spontaneous bacterial peritonitis by use of reagent strips. Hepatology 2003;37:893-896.

48.

Garcia-Tsao G: Treatment of spontaneous bacterial peritonitis with oral ofloxacin: inpatient or outpatient therapy? (letter). Gastroenterology 1996;111:1147-1149.

49.

Runyon BA, Akriviadis EA, Sattler FR, Cohen J: Ascitic fluid and serum cefotaxime and des-acetyl cefotaxime levels in patients treated for bacterial peritonitis. Dig Dis Sci 1991;36:1782-1786.

50.

Felisart J, Rimola A, Arroyo V, Perez-Ayuso RM, Quintero E, Gines P, Rodes J: Cefotaxime is more effective than ampicillin-tobramycin in cirrhotics with severe infections. Hepatology 1985;5:457-462.

51.

Navasa M, Follo A, Llovet JM, Clemente G, Vargas V, Rimola A, Marco F, Guarner C, Forne M, Planas R, Banares R, Castellas L, Jimenez De Anta MT, Arroyo V, Rodes J: Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis. Gastroenterology 1996;111:1011-1017.

52.

Runyon BA, McHutchison JG, Antillon MR, Akriviadis EA, Montano AA: Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. Gastroenterology 1991;100:1737-1742.

53.

Ricart E, Soriano G, Novella MT, Ortiz J, Sabat M, Kolle L, Sola-Vera J, Minana J, Dedeu JM, Gomez C, Barrio JL, Guarner C: Amoxicillin-clavulanic acid versus cefotaxime in the therapy of bacterial infections in cirrhotic patients. J Hepatol 2000;32:596-602.

54.

Hampel H, Bynum GD, Zamora E, El-Serag H: Risk factors for the development of renal dysfunction in hospitalized patients with cirrhosis. Am J Gastroenterol 2001;96:2206-2210.

55.

Terg R, Cobas S, Fassio E, Landeira G, Rios B, Vasen W, Abecasis R, Rios H, Guevara M: Oral ciprofloxacin after a short course of intravenous ciprofloxacin in the treatment of spontaneous bacterial peritonitis: Results of a multicenter, randomized study. J Hepatol 2000;33:564-569.

56.

Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del-Arbol L, Castells L, Vargas V, Soriano G, Guevara M, Gines P, Rodes J: Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999;341:403-409.

57.

Hoefs JC: Increase in ascites white blood cell and protein concentrations during diuresis in patients with chronic liver disease. Hepatology 1981;1:249-254.

58.

Bernard B, Grange J, Khac EN, Amiot X, Opolon P, Poynard T: Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: A meta-analysis. Hepatology 1999;29:1655-1661.

59.

Singh N, Gayowski T, Yu VL, Wagener MM: Trimethoprim-sulfamethoxazole for the prevention of spontaneous bacterial peritonitis in cirrhosis: a randomized trial. Ann Intern Med 1995;122:595-598.

60.

Soriano G, Guarner C, Teixido M, Such J, Barrios J, Enriquez J, Vilardell F: Selective intestinal decontamination prevents spontaneous bacterial peritonitis. Gastroenterology 1991;100:477-481.

61.

Novella M, Sola R, Soriano G, Andreu M, Gana J, Ortiz J, Coll S, Sabat M, Vila MC, Guarner C, Vilardell F: Continuous versus inpatient prophylaxis of the first episode of spontaneous bacterial peritonitis with norfloxacin. Hepatology 1997;25:532-536.

62.

Ortiz J, Vila MC, Soriano G, Minana J, Gana J, Mirelis B, Novella MT, Coll S, Sabat M, Andreu M, Prats G, Sola R, Guarner C: Infections caused by Escherichia coli resistant to norfloxacin in hospitalized cirrhotic patients. Hepatology 1999;29:1064-1069.

63.

Llovet JM, Rodriguez-Iglesias P, Moitinho E, Planas R, Bataller R, Navasa M, Menacho M, Pardo A, Castells A, Cabre E, Arroyo V, Gassull MA, Rodes J: Spontaneous bacterial peritonitis in patients with cirrhosis undergoing selective intestinal decontamination. J Hepatol 1997;26:88-95.

  Author Contacts

Todd A. Sheer, MD
Department of Internal Medicine, Division of Gastroenterology
Naval Medical Center San Diego, 34800 Bob Wilson Drive
San Diego, CA 92134 (USA)
Tel. +1 619 532 9795, Fax +1 619 532 9620, E-Mail tasheer@nmcsd.med.navy.mil

  Article Information

Number of Print Pages : 8
Number of Figures : 1, Number of Tables : 2, Number of References : 63

  Publication Details

Digestive Diseases (State-of-the-Art Clinical Reviews)

Vol. 23, No. 1, Year 2005 (Cover Date: 2005)

Journal Editor: Malfertheiner, P. (Magdeburg)
ISSN: 0257-2753 (print), 1421-9875 (Online)

For additional information: http://www.karger.com/ddi

  Drug Dosage / Copyright

Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.