Spontaneous bacterial peritonitis in adults: Clinical manifestations
- Bruce A Runyon, MD
Bruce A Runyon, MD
- Section Editor — Cirrhosis and Its Complications
- Clinical Professor of Medicine
- University of New Mexico, Division of Gastroenterology and Hepatology
- Special Hepatology Consultant to the Indian Health Service
- Northern Navajo Medical Center, Shiprock, New Mexico
Spontaneous bacterial peritonitis (SBP) is defined as an ascitic fluid infection without an evident intra-abdominal surgically-treatable source; it primarily occurs in patients with advanced cirrhosis . Typically, it is suspected when patients present with signs or symptoms of SBP. It may also be detected in patients who are asymptomatic who undergo paracentesis when admitted to the hospital for another reason. The diagnosis of SBP is established by a positive ascitic fluid bacterial culture, an elevated ascitic fluid absolute polymorphonuclear leukocyte (PMN) count (≥250 cells/mm3), and exclusion of secondary causes of bacterial peritonitis.
An elevated ascitic fluid absolute PMN count (≥250 cells/mm3) is adequate to make a presumptive diagnosis of SBP and to start empiric therapy. Too often, the paracentesis is performed after antibiotics are initiated and/or inadequate culture technique is used. In these situations, the cultures are regularly negative. (See "Spontaneous bacterial peritonitis in adults: Diagnosis".)
This topic will review the clinical manifestations of SBP. The pathogenesis of SBP, the diagnosis of SBP, differentiating SBP from a surgically-treatable cause of secondary bacterial peritonitis (eg, a perforated viscus), and the treatment and prophylaxis of SBP are discussed separately. (See "Pathogenesis of spontaneous bacterial peritonitis" and "Spontaneous bacterial peritonitis in adults: Diagnosis" and "Spontaneous bacterial peritonitis variants" and "Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis".)
IMPORTANCE OF EARLY RECOGNITION
It is important to recognize spontaneous bacterial peritonitis early in the course of infection because there is frequently a very short window of opportunity during which to intervene to ensure a good outcome. If the opportunity is missed, shock ensues, followed rapidly by multisystem organ failure . Survival is unlikely in patients who develop shock prior to initiation of empiric antibiotics. One report estimated that survival decreased by approximately 8 percent for each hour of delay in starting antibiotics in patients with septic shock . Another study has shown that delayed paracentesis in patients with SBP leads to a 2.7 fold increase risk of death; each hour of delay in paracentesis is associated with a 3.3 percent increase in in-hospital mortality . (See "Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis", section on 'Indications for antibiotic therapy'.)
Patients with spontaneous bacterial peritonitis (SBP) typically have advanced cirrhosis . The higher the Model for End-stage Liver Disease (MELD) score, the higher the risk of SBP . Spontaneous infection of noncirrhotic ascites (eg, ascites due to malignancy or heart failure) is unusual enough to be the subject of case reports and small series. (See "Pathogenesis of spontaneous bacterial peritonitis".)
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