1. Spontaneous Bacterial
Peritonitis(SBP)
Dr.Chakravarthy,P.S,MD
PG in Gastroenterology,
AMC/KGH

2. OVERVIEW
• Definitions & Classification
• Etiology & Pathophysiology
• Clinical features
• Investigations
• Treatment
• Prognosis
• Prevention

3. CLASSIFICATION
Spontaneous asc.fluid infection
• SBP
• MNB
• CNNA
Secondary bacterial peritonitis
Gut perforation/ non perforation
Polymicrobial bacterascites

4. DEFINITIONS
SBP
An infection of initially sterile ascitic fluid
without a detectable, surgically treatable
source of infection
Conn HO, 1969

5. • A positive ascitic fluid culture (essentially always
a monomicrobial infection) +
• elevated ascitic fluid absolute PMN count
(i.e., ≥250 cells/mm3)
without an evident intra-abdominal source of
infection that requires surgical treatment

6. DEFINITIONS
MNB
• a positive ascitic fluid culture for a single
organism +
• an ascitic fluid PMN count lower than 250
cells/mm3 +
• no evidence of an intra-abdominal surgically
treatable source of infection

7. DEFINITIONS
CNNA
• the ascitic fluid culture grows no bacteria +
• the ascitic fluid PMN count is 250 cells/mm3 or
greater +
• no antibiotics have been given (not even a
single dose) +
• no other explanation for an elevated ascitic
PMN count

8. DEFINITIONS
Secondary bacterial peritonotis
• ascitic fluid culture positive (usually for multiple
organisms) +
• PMN count is 250 cells/mm3 (0.25 × 109/L) or
greater +
• an intra-abdominal surgically treatable primary
source of infection

9. DEFINITIONS
Polymicrobial bacterascites
• Multiple organisms are seen on Gram stain or
cultured from the ascitic fluid +
• PMN count is lower than 250 cells/mm3 (0.25 ×
109/L)

10. Incidence
• 20% of all cirrhotics
• 50% at admission, 50% during hospital stay
• Cirrhosis and ascites carry a 10% annual risk of
ascitic fluid infection
• Of patients with cirrhosis who have SBP, 70%
are Child-Pugh class C

11. ETIOLOGY

12. PATHOPHYSIOLOGY

13. • Spontaneous variants of ascitic fluid almost
exclusively in the setting of severe liver disease
• Liver disease usually is chronic (cirrhosis), but
may be acute (fulminant hepatic failure) or
subacute (alcoholic hepatitis)

14. CNNA results from
• Previous antibiotic treatment
• Inadequate amount of fluid inoculated
• Spontaneously resolving SBP after clearing of all
bacteria
• Most of the spontaneous forms(upto 62%)
resolve by themselves

15. Risk factors
• Paracentesis
• GI hemorrhage,UTIs
• Deficient AF bactericidal activity (AF total protein
<1 g/dl, and/or AF C3 <13 mg/dl)
• Previous episode(s) of SBP

16. CLINICAL FEATURES

17. Diagnosis
• High index of suspicion
• Low threashold for paracentesis
• Clinical deterioration
• A clinical diagnosis without a paracentesis is
inadequate

18. Diagnostic Paracentesis
• All patients with ascites admitted to hospital as well as in
cirrhotics
• Signs of abdominal or systemic infection (abdominal pain
or tenderness, disturbed intestinal function, fever,
acidosis, peripheral leukocytosis)
• Patients presented with encephalopathy or worsened
renal functions.
AASLD,2013 guidelines(Class 1 ,Level B evidence)

19. ESSENTIALS OF PARACENTESIS
• ‘Skin needle’ to be replaced by sterile needle
• Blood culture bottles to be inoculated (atleast 10ml of
fluid)
• Cell count sample to be inoculated into EDTA container
• Cell count to be done manually(not on autoanalyzers)
EASL 2010 guidelines for SBP

20. Ascitic fluid analysis
• Total count
• Differential count
• Absolute PMN count
• Albumin
• Culture and sensitivity

21. Ascitic fluid culture
• Positive in upto 40% cases
• Most commonly – Gm neg.bacteria(E.coli) & Gm
positive cocci(Streptococcus)
• 30% GNBs resistent to quinolones & 30% to
trimethoprim-sulphamethoxazole
• Low resistance to 3rd gen.cephalosporins

22. Ascitic fluid culture
• Among culture positive samples,
2/3rd neutrocytic(SBP) &
1/3rd non-neutrocytic(MNB)
• Sec.BP  0% to 20% cases
• Polymicrobial  1 in 1000 samples

23. Ascitic fluid analysis
• Total protein – risk of SBP
• Glucose – PMN activity
(>50mg/dl in SBP, <50 in Sec.BP)
• LDH – 43+/- 20mU/ml(sterile fluid)
• Bilirubin – only for orange/brown fluid
> serum level (or) >6mg/dl viscus
perforation

24. • PMN > 250/Cmm + high suspicion of Sec.BP
test for asc.fluid total protein,glucose, LDH,ALP &
CEA
AASLD 2013,(Class 2A,Level B)

25. Leukocyte esterase (dipstick) test
• Efficacy of leukocyte esterase dipstick test as a
rapid test in diagnosis of spontaneous bacterial
peritonitis.
• Rerknimitr R, Rungsangmanoon W, Kongkam P, Kullavanijaya P.
• Gastroenterology Unit, Department of Internal Medicine, Faculty of
Medicine, Chulalongkorn University, Bangkok
• World J Gastroenterol. 2006 Nov 28;12(44):7183-7
• CONCLUSION:
• Dipstick test can be used as a rapid test for screening of SBP. The
higher cut off colorimetric scale has a better specificity and positive
predictive value but a lower sensitivity

26. Leukocyte esterase (dipstick) test
• Bedside leucocyte esterase reagent strips with
spectrophotometric analysis to rapidly exclude
spontaneous bacterial peritonitis: a pilot study.
• Gaya DR, David B Lyon T, Clarke J, Jamdar S, Inverarity D, Forrest
EH, John Morris A, Stanley AJ.
• Department of Gastroenterology, Glasgow Royal Infirmary,
Glasgow, UK.
• Eur J Gastroenterol Hepatol. 2007 Apr;19(4):289-95
• Conclusion :Bedside leucocyte esterase strips, spectrophotometrically
read, can reliably exclude spontaneous bacterial peritonitis in patients with
cirrhotic ascites. In our series, a negative strip result effectively ruled out
this important condition, and suggests that the requirement for manual
polymorphonuclear leucocyte counting in this setting could be removed

27. Leukocyte esterase (dipstick) test
• Review article: the utility of reagent strips in the
diagnosis of infected ascites in cirrhotic patients.
• Nguyen-Khac E, Cadranel JF, Thevenot T, Nousbaum JB.
• Hepato-Gastroenterology, Amiens University Hospital, CHU Nord,
place Victor Pauchet, France
• Aliment Pharmacol Ther. 2008 Aug 1;28(3):282-8
• CONCLUSION:
Use of reagent strips for the diagnosis of SBP cannot be
recommended, in view of low sensitivity and a high risk of false
negatives, especially in patients with SBP and low
polymorphonuclear count.

28. Ascitic fluid Lactoferrin
• Ascitic Fluid Lactoferrin for Diagnosis of
Spontaneous Bacterial Peritonitis
• Mansour A. Parsi, Sherif N. Saadeh, Nizar N. Zein, Gary L. Davis
• Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
• Gastroenterology,Volume 135, Issue 3 , 803-807, September 2008
• Conclusions: AFLAC can serve as a sensitive and specific test for diagnosis
of SBP. Qualitative bedside assays for the measurement of AFLAC can be
developed easily and may serve as a rapid and reliable screening tool for
SBP in patients with cirrhosis

29. Granulocyte elastase
• Rapid detection of spontaneous bacterial peritonitis by
granulocyte elastase latex immunoassay and reagent
strip.
• Yamazaki M, Sano R, Kuramoto C, Yoshiji H, Uemura M, Fukui
H, Kamiya M, Okamoto Y.
• Central Clinical Laboratory, Nara Medical University Hospital,
Kashihara 634-8522, Japan
• Rinsho Byori. 2011 Jun;59(6):549-58
• Results :The sensitivity, specificity, and positive and negative
predictive values of the reagent strips for diagnosis of SBP were
92.9%, 90.9%, 76.5%, and 97.6%, respectively.
• Conclusion : GE-LIA reagent strips are rapid and sensitive and can
aid diagnosis of SBP.

30. • Imaging
rarely required for SBP
useful for Sec.BP

32. Differential diagnosis
• Tuberculosis
• Acute pancreatitis
• Peritoneal carcinomatosis
• Peritoneal hemorrhage

33. TREATMENT
Ideal timing to treat….
As early as possible …..if
• Temperature >37.8*C(100*F)
• Abdominal pain/ tenderness
• Altered mental status
• Start empirical i.v antibiotic (broad-spectrum)
+ supportive measures
AASLD2013,(Class 1, Level A)

34. Which drug to start with…?
• Third generation cephalosporin
(preferably cefotaxime 2gm,IV, 8th hourly)
AASLD 2013,(Class 1, Level A)
• Ofloxacin 400mg 12th hourly
AASLD 2013,(Class 2A,Level B)
(exclude prior exposure to
quinolones,vomiting,shock,creat>3mg/dl, Gr.II or
more encephalopathy prior to therapy)

35. TREATMENT
• PMN<250 + symptoms/signs of infection
should receive empiric antibiotic
(till the culture report)
AASLD 2013,(Class 1, Level B)

36. TREATMENT
• PMN > 250/cmm + clinical picture suggestive
treat just like classical SBP (irrespective of
culture report)
EASL 2010 guidelines for SBP

37. TREATMENT
• Albumin ..?
1.5gm/kg body wt within 6hrs of detection
&
1.0gm/kg body wt on 3rd day
(PMN>250, Creat>1mg/dl, BUN>30mg/dl ,
total bilirubin>4mg/dl)
AASLD 2013,(Class 2A, Level B)

38. • Albumin Infusion Improves Outcomes of Patients
With Spontaneous Bacterial Peritonitis: A Meta-
analysis of Randomized Trials.
• Salerno F, Navickis RJ, Wilkes MM.
• Dipartimento di Medicina Interna, Università degli Studi di Milano,
Policlinico IRCCS San Donato, Milano, Italy.
• Clin Gastroenterol Hepatol. 2013 Feb;11(2):123-130
CONCLUSIONS:
In a meta-analysis of 4 RCTs (288 patients), albumin infusion
prevented renal impairment and reduced mortality among patients
with SBP

39. Clinical Gastroenterology and hepatology,2012,Vol.10,No.3

41. Repeat paracentesis
• Clinical deterioration –
fever, abd.pain, renal failure,altered mental
status,GI bleed,peripheral leukocytosis

42. Predictors of poor outcome
• Age >60yr
• Community Vs hospital acquired SBP
• S.creatinine >3mg/dl
• BUN > 30mg/dl
• Child – Pugh score >9

43. PROGNOSIS
• <5% mortality (48-95% in the past)
• Mortality in cured pts is d/t worsening of
underlying liver disease/ GI bleeding
• 100% mortality in Sec.BP without surgery
• 50% mortality with laparotomy

44. PREVENTION
• IV Ceftriaxone/oral Norfloxacin BD for 7days in
all GI beeds with cirrhosis (Class 1,Level A)
• Daily norfloxacin (longterm) in survivors of SBP
(Class 1,Level A)
AASLD 2013

45. • Cirrhosis & ascites but no GI bleed
longterm Norfloxacin indicated if asc.fluid total
protein < 1.5gm/dl & one of the following present
- S.creatinine >/= 1.2mg/dl
- BUN >/= 25mg/dl
- S.Na+ </= 130meq/L
- CTP score >/= 9
AASLD 2013 (Class1 ,Level B)

46. • Primary Prophylaxis of Spontaneous Bacterial
Peritonitis Delays Hepatorenal Syndrome and
Improves Survival in Cirrhosis
• Javier Fernández, Miquel Navasa
• Gastroenterology, Volume 133, Issue 3, September 2007, Pages
818-824

48. Take Home message
• Infection of asc.fluid is often underdiagnosed
• All admitted pts should undergo diagnostic
paracentesis
• Meticulous care required while processing the
samples
• Try to ruleout secondary causes in all possible
cases
• Rapid bedside tests help in changing outcome

49. Take Home message
• Early antibiotic therapy grossly alters the
final outcome
• Primary prophylaxis has a role in
preventing systemic complications and
improving survival

50. REFERENCES
• Sleisenger text book of GI and liver diseases,9th edition
• Schiff’s diseases of the liver,11th edition
• AASLD guidelines for ascites & SBP(2013)
• EASL guidelines for ascites and SBP(2010)
• Cochrane metaanalysis database for SBP treatment
• Jour of clin gastroenterology and hepatology,Feb.2013
• Gastroenterology,vol.133,Sept,2008
• Aliment Pharmacol Ther. 2008 Aug