Peritonitis, Spontaneous Bacterial & Secondary

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Peritonitis, Spontaneous Bacterial & Secondary

Christopher F. Carpenter, M.D.; Nick Gilpin, D.O.
09-23-2010
PATHOGENS
• Escherichia coli
• Klebsiella species
• Enterobacter species
• Other Enterobacteriaceae
• Streptococcus pneumoniae
• Streptococci and enterococci
• Polymicrobial (secondary peritonitis)
• Anaerobes (secondary peritonitis)
CLINICAL
• Patients with ascites, fever (may be low-grade or absent) and/or abdominal pain should be evaluated for spontaneous bacterial peritonitis (SBP, also known as primary peritonitis) or other forms of peritonitis.
• Signs and symptoms of SBP are often quite subtle compared to patients with secondary peritonitis, which is characteristically more inflammatory.
• SBP should be suspected in all patients with ascites (especially patients with cirrhosis) and clinical decompensation.
• The possibility of SBP should be considered in 1) all cirrhotic patients on admission to hospital, 2) all patients with ascites who develop hepatic encephalopathy, renal impairment, or altered GI motility, and 3) all patients with ascites suffering from a GI bleed (empirical treatment/prophylaxis may be indicated).
• Secondary peritonitis = peritonitis with a surgically-amenable source (e.g., appendicitis, diverticulitis; routinely polymicrobial).
• Tertiary peritonitis = relatively new term referring to persistence of peritonitis/abscess following apparent adequate treatment of primary or secondary peritonitis.
DIAGNOSIS
• SBP clinical findings: fever (70%), ascites (may be small amount), abdominal pain/tenderness (50%); many will have no classic findings to suggest infection.
• SBP diagnostic criteria: ascites with > 250 PMN cells/ml with positive cultures and no surgically-amenable intraabdominal source of infection.
• SBP variant forms: culture-negative neutrophilic (PMN>250) ascites (CNNA - up to 40%) and monomicrobial non-neutrophilic (PMN<250) bacterascites (MNB).
• Secondary peritonitis clinical findings: more commonly with peritoneal findings of an acute abdomen - rebound tenderness and guarding, sepsis, and radiographic findings defining the source and revealing free air and potentially early abscess development.
• Differentiation of SBP from secondary peritonitis (if surgical source not identified): secondary peritonitis results in much higher WBC count (often >10,000), with polymicrobial culture results. Secondary peritonitis also frequently involves one or more of the following: ascitic fluid protein concentration > 1 g/dL, glucose < 50 mg/dL, or LDH > upper limit of normal for serum value.
• Culture of ascitic fluid in a blood culture bottle may result in a higher culture yield for SBP (from 50% conventional culture to approximately 80%).
• 
TREATMENT
SBP Treatment
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• Cefotaxime 2g IV q8h or ceftriaxone 1g IV once daily
• Recent single center report of effectiveness of cefotaxime +albumin in reducing mortality and irreversible renal impairment. Addition of albumin may be more beneficial in patients with creatinine> 1 mg/dL, BUN > 30 mg/dL, or bilirubin > 4 mg/dL.
• Ciprofloxacin 400mg IV q12h or levofloxacin 500mg IV once daily or moxifloxacin 400mg IV once daily.
• Ofloxacin has been reported effective as an oral alternative at 400mg PO twice daily.
• Ticarcillin-clavulanate 3.1g IV q6h or piperacillin-tazobactam 3.375g IV q6h or 4.5g IV q8h.
• Ertapenem 1.0g IV once daily; for pts with resistant pathogens: imipenem 500mg IV q6h, meropenem 1.0g IV q8h, or doripenem 500mg IV q8h.
• Cefepime 1-2g IV q8h for pts with resistant pathogens .
• Use ascitic culture results to refine antibiotic choice (if necessary).
• Repeated paracentesis may be considered but is usually not necessary; PMN's < 250 with negative culture support an abbreviated course (< 5 days).
• Duration of 5-7 days likely adequate; traditional 10-14 days is longer than needed unless complicated patients or positive blood cultures.
• Culture-negative neutrophilic ascites (CNNA) has clinical, prognostic, and therapeutic characteristics similar to spontaneous bacterial peritonitis (SBP) and should be treated in a similar fashion. Patients with monomicrobial non-neutrophilicbacterascites (MNB) typically respond similar to CNNA and SBP if the patient is symptomatic; asymptomatic patients usually do not need antibiotics and observation is appropriate, but consideration of TB should be entertained.
SBP prophylaxis
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• Prophylaxis recommended after first episode of SBP (secondary prophylaxis).
• In patients with cirrhosis and ascites, but no GI bleeding, primary prophylaxis can be considered if the ascitic fluid protein < 1.5 g/dL, and one of the following criteria are met: serum creatinine> 1.2 mg/dL, BUN > 25 mg/dL, serum sodium < 130 mEq/L, or Child-Pugh score > 9 with bilirubin > 3 mg/dL.
• Trimethoprim-sulfamethoxazole 1 DS PO once daily.
• Norfloxacin 400mg PO once daily
• Ciprofloxacin 750mg PO once weekly
• If GI bleeding: ceftriaxone 1g IV daily or norfloxacin 400mg orally twice daily should be given for 7 days to prevent bacterial infections in patients with both cirrhosis and GI bleeding.
Secondary Peritonitis Treatment
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• Operative management is indicated to eliminate the source of contamination, reduce the bacterial load, and prevent recurrence.
• Empiric antimicrobial coverage should include coverage of gram-negative aerobes, enteric streptococci, and anaerobes.
• Upper tract source (e.g., perforated ulcer) usually predominantly gram-positive infections; lower tract (distal small bowel or colon) generally results in anaerobic and gram-negative aerobes.
• Duration can generally be limited to 4 to 7 days, longer if leukocytosis/left shift and fever are slow to resolve or source control inadequate.
• Ticarcillin-clavulanate 3.1g IV q6h (for mild-to-moderate severity infections) or piperacillin-tazobactam 3.375g IV q6h or 4.5g IV q8h (for more severe infections, higher risk patients, healthcare-associated or hospital-acquired pathogens).
• Alternatives for mild-moderate community-acquired infections include: metronidazole plus 3rd/4th generation cephalosporin or fluoroquinolone or aztreonam; ertapenem1.0g IV once daily.
• Additional alternatives for mild-moderate community-acquired infections include: cefoxitin 2gm IV q6h, tigecycline 100mg IV x 1 then 50mg IV q12h, or moxifloxacin 400mg IV every day.
• Alternatives for pts with resistant pathogens:imipenem 500mg IV q6h or meropenem 1.0g IV q8h ordoripenem 500mg IV q8h; metronidazole plus cefepime2gm IV q8-12 hours, metronidazole plus an antipseudomonalfluoroquinolone.
Catheter-associated Peritonitis
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• Treat CAPD-associated peritonitis empirically with vancomycinplus gram-negative coverage, pending cultures.
• Catheter may need removal (especially for yeast, S. aureus, and difficult-to-treat gram-negative bacteria such as Pseudomonas aeruginosa, and Stenotrophomonasmaltophilia).

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