Potential Preventability of Spontaneous Bacterial Peritonitis: Study of Adherence Practices of AASLD Guidelines on Antibiotic Prophylaxis for SBP at a University Hospital

Abstract

Purpose: Antibiotic prophylaxis can reduce the incidence of the first episode and of recurrence of spontaneous bacterial peritonitis (SBP) in high risk cirrhotic patients. However, recent available data suggest that SBP prophylaxis may be underused. It is unclear how many cases of cirrhosis that develop SBP might actually be prevented through encouraging antibiotic prophylaxis. The aim of this study is to determine the number of “preventable” cases of SBP and adherence to standard guideline of use of antibiotic prophylaxis. Methods: We reviewed the medical records of patients diagnosed with SBP between Jan 2004 and Feb 2009 at a university hospital. SBP was defined as ≥250 PMN/ml in the ascitic fluid (AF). AASLD Guidelines (2004) for SBP prophylaxis include prior SBP; gastrointestinal (GI) hemorrhage; AF protein concentration ≤lg/dL or serum bilirubin ≥2.5mg/dL. “Preventable (P) SBP” is defined as SBP occurring where prophylaxis was indicated but was not administered. “Non-preventable (NP) SBP” is defined as SBP that occurred despite proper adherence to the guidelines. “Spontaneous (S) SBP” were those cases of SBP occurring in the absence of a documented indication for prophylaxis. Results: A total of 259 cirrhotics underwent paracentesis. 29 patients fulfilled inclusion criteria. 230 patients were excluded due to (1) AF PMN<250 cell/ ml (n=173), (2) received antibiotics for another indication (n=5), (3) immunocompromised (n=6), and (4) incomplete AF analysis (n=46). 62% of 29 patients were considered “P-SBP” [Child-Pugh (CP) Class B (n=4, 22%); C (n=14, 77%)]. One (3%) patient was considered “NP-SBP” and 10 (34%) were defined “S-SBP” [CP Class B (n=5, 50%); C (n=5, 55%)]. Of the P-SBP, the overlooked indications for prophylaxis were serum bilirubin ≥2.5mg/dL (38%), GI hemorrhage (33%), AF total protein<lg/dl (16%), and prior SBP (11%), respectively. 77% of the P-SBP were community-acquired; 22% nosocomial. Extra-peritoneal infection occurred in 6/18 (33%) patients with P-SBP [bacteremia 4, UTI 1 and pneumonia 1]. In-hospital mortality in the P-SBP was 16% (n=3). Only 33% (8/16) of patients in all groups who survived SBP received long-term outpatient prophylaxis after discharge. Conclusion: Majority of SBP could be prevented by adhering to the AASLD guidelines. Serum bilirubin ≥2.5 mg/dL and GI hemorrhage are the most frequently overlooked indications for SBP prophylaxis. Studies identifying the reasons for non-adherence to guidelines and developing interventions to increase utilization are warranted.