Internal Medicine

0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:50

1366 Spontaneous Bacterial Peritonitis

■polymicrobial bacterascites: gut perforation due to paracentesis

needle, with diagnosis based on ascitic fluid PMN <250 cells/mm3

and polymicrobial Gram stain and/or culture

management

What to Do First

■diagnostic paracentesis, including cell count and culture

■empirical broad-spectrum intravenous antibiotic without delay

General Measures

■err on the side of overtreatment if initial presentation is uncertain

■avoid nephrotoxic medications, including aminoglycosides

specific therapy

Indications for Treatment

■ascitic fluid PMN > 250 cells/mm3

■convincing signs and symptoms of infection

Treatment Options for SBP

■cefotaxime or a similar third-generation cephalosporin antibiotic of

choice for spontaneous ascitic fluid infection

■intravenous albumin can further reduce the morbidity and mortality

oral

■ofloxacin effective in uncomplicated SBP

Treatment of Other Spontaneous Ascitic Fluid Infections

■treatment of MNB

➣symptomatic patients without neutrocytic ascites: empiric ini-

tiated on cefotaxime, with follow-up paracentesis performed at

48 hours; if culture results demonstrate no growth 2–3 days later,

antibiotics can be discontinued

➣asymptomatic patients: do not need treatment immediately but

require repeat paracentesis for cell count and culture; if ascitic

fluid becomes neutrocytic or signs and symptoms of infection

develop, antibiotics should be initiated

■treatment of CNNA

➣patient is already initiated empirically on antibiotics since the

turn-around time for ascitic fluid culture takes a few days

➣repeat paracentesis; a decline in ascitic fluid PMN count con-

firms response and warrants a few more days of antibiotics; a

stable ascitic fluid PMN count suggests a nonbacterial cause and

warrants further investigation