Abstract
Spontaneous bacterial peritonitis (SBP) has a high mortality rate; early antimicrobial therapy is essential for improving patient outcomes. Given that cirrhotic patients are often coagulopathic, the perceived risk of bleeding may prevent providers from performing a paracentesis and ruling out this potentially deadly disease.We examine the pathophysiology and risk factors for SBP, and current guidelines for its diagnosis and treatment. We then review the time-sensitive nature of performing a paracentesis, and the current controversies and contraindications for performing this procedure in patients at risk for SBP.Cirrhotic patients with ascites and clinical suspicion for SBP—abdominal pain or tenderness, fever or altered mental status—should have a diagnostic paracentesis. Although most patients with cirrhosis and liver dysfunction will have prolonged prothrombin time, paracentesis is not contraindicated. Limited data support platelet administration prior to paracentesis if <40,000-50,000/μL. Timely antimicrobial therapy includes a third-generation cephalosporin for community-acquired infection; nosocomial infections should be treated empirically with a carbapenem or with piperacillin-tazobactam, or based on local susceptibility testing. Patients with gastrointestinal (GI) hemorrhage should receive ceftriaxone prophylactically for GI hemorrhage.SBP has a high mortality rate. Early diagnosis and antimicrobial therapy are essential for improving patient outcomes. Cirrhotic patients with ascites with clinical suspicion for SBP, abdominal pain or tenderness, altered mental status or fever should have a diagnostic paracentesis performed prior to admission unless platelets <40,000-50,000/μL.
Highlights
BackgroundBetween 2006 and 2011, there were a total of 3,127,986 cirrhosis-associated emergency department (ED) visits in the United States
According to the American Association for the Study of Liver Diseases (AASLD), “If ascitic fluid infection is suspected, ascetic fluid should be cultured at the bedside in aerobic and anaerobic blood culture bottles prior to initiation of antibiotics (Class 1, Level B),” noting that bacterial growth occurs 80% of the time when collected in culture bottles, compared to only 50% when collected in other containers [25]
spontaneous bacterial peritonitis (SBP) has a high mortality rate, and early diagnosis and antimicrobial therapy are essential for improving patient outcomes
Summary
Serum creatinine (Cr) levels may be elevated in patients with cirrhosis as acute kidney injury is common in this population, and may be due to many causes including hepatorenal syndrome, shock, nephrotoxic medications, or intrinsic kidney disease [20] While these laboratory abnormalities are common in patients with cirrhosis and ascites, they are neither sensitive nor specific for the diagnosis of SBP. These data demonstrate the safety of paracentesis in the cirrhotic population, as supported by clinical guidelines [25]. Observation or admission should be considered in patients with any clinical signs of infection, even with normal ascetic fluid
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