What is Spontaneous Bacterial Peritonitis?

Spontaneous bacterial peritonitis, or SBP, is a condition that refers to a sudden infection of ascites. Ascites is unusual fluid build-up in the stomach, and in this case, there’s no clear or identifiable source of the infection. SBP is almost always found in patients with a disease called cirrhosis (scar tissue in the liver) who are also experiencing ascites. The signs that doctors look for to suspect SBP include stomach pain, fever, or changes in mental state. Please note that there’s no universally agreed upon method to diagnose SBP, and some patients might not even show obvious stomach pain.

What Causes Spontaneous Bacterial Peritonitis?

Spontaneous bacterial peritonitis (SBP) is usually (in 75% of cases) caused by “gram-negative aerobic organisms” – a type of bacteria. The bacteria Klebsiella pneumoniae accounts for half of these cases. There are also instances where SBP is caused by “gram-positive aerobic microorganisms”, another type of bacteria. These are most often Streptococcus pneumoniae or Viridans group streptococci.

Our bodies naturally have fluid in an area of the abdomen called the ascitic fluid. This fluid usually has a high level of oxygen, making it difficult for anaerobic (oxygen-hating) organisms to survive. This means these types of bacteria are not usually seen in cases of SBP. It’s also common that only one type of bacteria is involved in causing the infection. However, there are a few cases where more than one type of bacteria is involved.

SBP usually happens in people who have had long-term problems with their liver. The Child-Pugh scale is used to look at how severe liver disease is. If a person has a high score of 10 to 15 on this scale, their chances of surviving a year is about 45%, and surviving two years is about 35%. People with the most severe liver disease (decompensated cirrhotic patients) are most at risk of getting SBP.

Additional things that can increase someone’s risk of getting SBP include having had SBP before, a lower level of certain proteins in the body, and taking long-term medication to decrease stomach acid (proton pump inhibitor therapy). This medication can increase the pH in the stomach, which promotes gut bacterial growth and movement.

While SBP is usually seen in adults with a build-up of fluid in the abdomen (known as ascites), most children with SBP don’t have this symptom. The reason behind this isn’t yet known.

Risk Factors and Frequency for Spontaneous Bacterial Peritonitis

SBP, a medical condition, can affect both adults and children, but it’s particularly common in newborns and five-year-olds. It’s mostly seen in people with cirrhosis, a liver disease. Nonetheless, it can also occur as a result of any condition that causes ascitic fluid to build up. This can be diseases like liver disease, Budd-Chiari syndrome, heart failure, lupus, kidney disease, or various kinds of cancer. SBP generally doesn’t have a very good outlook.

About 10 to 25% of people with ascites, the medical term for this build-up of fluid, will develop SBP. Furthermore, this condition carries a 20% hospital mortality rate, meaning that 20% of those hospitalized due to SBP don’t survive.

  • People who’ve had SBP once are more likely to get it again, and it may be resistant to drugs the next time around.
  • The risk of developing SBP goes up with age.
  • Those using proton-pump inhibitors, which are a type of medication, also have a higher chance of developing SBP.
  • The same applies to those undergoing SBP prevention measures, like selective intestinal decontamination.

Signs and Symptoms of Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis, or SBP, should be considered as a potential diagnosis for all patients who come in with ascites, especially if the person’s condition has recently worsened. A majority of those with SBP will have fever, chills, and abdominal pain. However, some might not show any symptoms, and SBP is unexpectedly discovered. An increase in body temperature is the most frequent symptom in SBP patients. This symptom is especially helpful as usually, patients with cirrhosis have a lower-than-normal body temperature.

Besides these, other signs include diarrhea, paralytic ileus (intestinal obstruction), new or worsening encephalopathy (changes in mental state) with no other cause, worsening renal (kidney) failure, or fluid build-up in the abdomen which doesn’t reduce with diuretic medications (those that help remove excess fluid).

During a physical exam, most patients will feel pain in the abdomen. However, the level of discomfort can vary, from mild pain to severe tenderness and defensive muscle contraction. It’s crucial to note that not having a fever does not eliminate the possibility of SBP.

  • Fever, chills, and abdominal pain
  • Diarrhea and paralytic ileus
  • New or worsening mental state changes
  • A worsening in kidney function
  • Fluid build-up in the abdomen not improving with diuretic medications
  • Abdominal sensitivity or severe tenderness during physical exam

Testing for Spontaneous Bacterial Peritonitis

When it comes to treating a condition called spontaneous bacterial peritonitis (SBP), timing is everything. A fast response can prevent the problem from worsening into a state of severe shock or organ failure. To do this, doctors will need to start antibiotic therapy as soon as possible.

One of the first steps is performing fluid analysis—like testing the cell count, fluid composition, and pH levels—in patients who are suspected to have SBP. There are two ways to do this: The first is through diagnostic paracentesis, a procedure that involves removing fluid from the abdominal cavity, and the second is by withdrawing fluid from an existing peritoneal catheter (a tube placed into the abdominal cavity), which some patients may already have due to prior treatments like dialysis. For patients with only a bit of fluid accumulation, doctors will use ultrasound to guide them during paracentesis.

Blood and urine samples are collected too. The results of these tests can help doctors identify the source of the infection and, thus, plan antibiotic therapy more effectively.

Next, doctors will check the count of polymorphonuclear leukocytes (PMN)—a group of white blood cells—in the fluid sample. If there are more than 500 cells for every microliter of fluid, this could be a strong indicator of SBP. The count can go as low as 250 cells per microliter, but while this improves the chance of detecting SBP, it might bring in some false results as well. Nonetheless, this PMN count is generally accepted as a reliable basis for diagnosing SBP and starting antibiotics.

In cases where an internal tear or hole (perforation) might be causing SBP, doctors may arrange for an imaging test, like a computed tomography (CT) scan. A CT scan is preferred over a simple X-ray because it’s more accurate at detecting smaller perforations.

Lately, researchers have been exploring a new diagnostic method that uses a special strip, like those in home pregnancy tests, which can detect a substance called leukocyte esterase in the fluid. It shows a 100% accuracy rate when compared to manual PMN counting, highlighting its potential as a faster and more convenient way to diagnose SBP. However, more comprehensive testing is needed before it becomes common practice.

Lastly, there are several high-risk groups for SBP:

– Patients with both gastrointestinal bleeding and liver cirrhosis.
– Patients who have had SBP before.
– Patients with liver cirrhosis who have low protein in their ascitic fluid (< 1.5g/dl) and signs of kidney failure (creatinine > 1.2 mg/dl).
– Hospitalized cirrhotic patients who are being treated for another condition and have a very low concentration of protein in their ascitic fluid (< 1g/dl or 10 g/L).

Treatment Options for Spontaneous Bacterial Peritonitis

If a patient is suspected of having Spontaneous Bacterial Peritonitis (SBP), which is an infection of the fluid in the belly, they are typically given an antibiotic directly into their veins. However, if the patient has recently taken a specific type of antibiotics known as beta-lactams, or the SBP was diagnosed in a hospital setting, the choice of antibiotics will depend on the specific type of bacteria found in their belly fluid.

Patients with a large amount of white blood cells (specifically, polymorphonuclear neutrophils, or PMN) in their belly fluid should be admitted to the hospital as soon as possible and given antibiotics. Doctors then need to keep a close eye on the patient’s condition, by re-examining the belly fluid to see if the white blood cell count has dropped. If there’s no improvement after two days, this might suggest a serious issue such as a hole in the gut, or an abscess which is a pocket filled with pus, and surgery might be needed.

Patients with SBP who also show signs of possible kidney problems (like higher levels of certain substances in the blood, such as creatinine, blood urea nitrogen or total bilirubin), should also receive a protein called albumin into their veins. This has been seen to reduce both death rates in the hospital and kidney damage, compared to only using antibiotics.

Some patients who are at high risk may benefit from taking antibiotics as a preventive measure. This includes patients who have previously had SBP, have very low levels of protein in their belly fluid, or are dealing with a gastrointestinal bleed. However, there’s a concern that frequent use of antibiotics can result in bacteria becoming resistant, especially in healthcare centers that rely heavily on a particular type of antibiotics called fluoroquinolones for the prevention of SBP. If this happens, other antibiotics such as cefotaxime, piperacillin-tazobactam or carbapenems might be used.

Kidney failure is a major concern for patients with SBP and can occur in 30 to 40 percent of these patients. The risk of this happening can be reduced by giving the patient albumin intravenously if they show signs of possible kidney problems. Additionally, adding medications like octreotide or midodrine can be helpful if kidney failure develops.

The following conditions can be potential causes of certain symptoms:

  • Perforated viscus (an organ in the abdomen has a hole in it)
  • Perinephric abscess (an abscess, or collection of pus, around a kidney)
  • Pyelonephritis (kidney infection)
  • Diverticulitis (inflammation of pouches in the colon)
  • Appendicitis (inflammation of the appendix)
  • Mesenteric ischemia (poor blood flow to the intestines)

What to expect with Spontaneous Bacterial Peritonitis

If treated properly, the risk of death from infection in SBP (Spontaneous Bacterial Peritonitis) is quite low. However, the risk of death increases significantly in those patients who develop a severe response to infection known as sepsis. But, if patients receive the right antibiotics promptly, they can have better outcomes.

In hospitals, the risk of dying from factors not related to the infection in SBP patients could be as high as 20 to 40 percent. Moreover, the risk of death is 70 and 80 percent within one to two years respectively. Despite the short-term outcome of SBP, patients with liver disease severe enough to develop SBP tend to have a poor long-term outlook.

Additionally, for those who survive SBP and show suitable characteristics for the procedure, a liver transplant could be an option to consider.

Possible Complications When Diagnosed with Spontaneous Bacterial Peritonitis

  • Kidney failure
  • Serious whole-body infection known as sepsis
  • Liver failure or insufficiency
  • Tense ascites, which refers to a substantial buildup of fluid in the abdomen
  • Bleeding after having a paracentesis, a procedure to remove fluid from the abdomen
  • Bowel perforation, or a hole in the intestine, after having a paracentesis
  • Spontaneous fungal peritonitis, an infection in the abdominal cavity caused by fungus

Preventing Spontaneous Bacterial Peritonitis

If someone has serious bleeding in their stomach or intestines, it’s important that they receive medical treatment right away. This situation can quickly become dangerous, so immediate and forceful intervention may be needed.

Patients who have ascitic fluid (liquid that accumulates in the abdomen) which has a protein concentration of less than 1g/dl, should be treated in a hospital setting. This is because lower protein levels can make them more prone to infections, thus required medical supervision is crucial.

People who have had Spontaneous Bacterial Peritonitis (SBP, a type of infection in the abdomen) within the past year should take antibiotics for an extended period. This is done to prevent future instances of the condition, as they are at a higher risk of getting it again.

For those who have a history of SBP, long-term at-home treatment with specific antibiotics such as trimethoprim-sulphamethoxazole or ciprofloxacin/norfloxacin is recommended. These antibiotics help ward off bacteria to prevent another bout of SBP.

Frequently asked questions

The prognosis for Spontaneous Bacterial Peritonitis (SBP) can vary depending on several factors, but overall it is not very good. The condition carries a 20% hospital mortality rate, meaning that 20% of those hospitalized due to SBP do not survive. In addition, the risk of death from factors not related to the infection in SBP patients in hospitals could be as high as 20 to 40 percent.

Spontaneous Bacterial Peritonitis (SBP) is usually caused by gram-negative aerobic organisms, such as Klebsiella pneumoniae, or gram-positive aerobic microorganisms, such as Streptococcus pneumoniae or Viridans group streptococci. It typically occurs in people with long-term liver problems, particularly those with severe liver disease. Other factors that can increase the risk of SBP include a history of SBP, lower levels of certain proteins in the body, and long-term use of proton pump inhibitor therapy.

The signs and symptoms of Spontaneous Bacterial Peritonitis (SBP) include: - Fever, chills, and abdominal pain - Diarrhea and paralytic ileus (intestinal obstruction) - New or worsening mental state changes (encephalopathy) with no other cause - Worsening kidney function (renal failure) - Fluid build-up in the abdomen that does not improve with diuretic medications - Abdominal sensitivity or severe tenderness during a physical exam It is important to note that not all patients with SBP will exhibit all of these symptoms. Some patients may not show any symptoms at all and SBP may be unexpectedly discovered. Additionally, having a normal body temperature does not eliminate the possibility of SBP, as an increase in body temperature is the most frequent symptom in SBP patients.

The types of tests needed for Spontaneous Bacterial Peritonitis (SBP) include: 1. Fluid analysis: This involves testing the cell count, fluid composition, and pH levels in the abdominal cavity fluid. This can be done through diagnostic paracentesis or by withdrawing fluid from an existing peritoneal catheter. 2. Blood and urine samples: These samples are collected to help identify the source of the infection and plan antibiotic therapy more effectively. 3. Polymorphonuclear leukocyte (PMN) count: Checking the count of PMN cells in the fluid sample can be a reliable basis for diagnosing SBP. If there are more than 500 cells per microliter of fluid, it could indicate SBP. 4. Imaging tests: In cases where an internal tear or hole might be causing SBP, an imaging test like a computed tomography (CT) scan may be arranged. CT scans are more accurate at detecting smaller perforations compared to simple X-rays. 5. Leukocyte esterase test: Researchers have been exploring a new diagnostic method using a special strip that can detect leukocyte esterase in the fluid. This test shows potential as a faster and more convenient way to diagnose SBP, but further testing is needed before it becomes common practice.

The doctor needs to rule out the following conditions when diagnosing Spontaneous Bacterial Peritonitis: - Perforated viscus (an organ in the abdomen has a hole in it) - Perinephric abscess (an abscess, or collection of pus, around a kidney) - Pyelonephritis (kidney infection) - Diverticulitis (inflammation of pouches in the colon) - Appendicitis (inflammation of the appendix) - Mesenteric ischemia (poor blood flow to the intestines)

The side effects when treating Spontaneous Bacterial Peritonitis may include: - Kidney failure - Serious whole-body infection known as sepsis - Liver failure or insufficiency - Tense ascites, which refers to a substantial buildup of fluid in the abdomen - Bleeding after having a paracentesis, a procedure to remove fluid from the abdomen - Bowel perforation, or a hole in the intestine, after having a paracentesis - Spontaneous fungal peritonitis, an infection in the abdominal cavity caused by fungus

A gastroenterologist or an infectious disease specialist.

About 10 to 25% of people with ascites will develop SBP.

Spontaneous Bacterial Peritonitis (SBP) is typically treated with antibiotics that are administered directly into the patient's veins. The choice of antibiotics depends on factors such as the patient's recent use of beta-lactam antibiotics or whether the SBP was diagnosed in a hospital setting. If the patient has a large amount of white blood cells in their belly fluid, they should be admitted to the hospital and given antibiotics. The patient's condition should be closely monitored, and if there is no improvement after two days, surgery may be necessary. Patients with SBP and signs of possible kidney problems should also receive a protein called albumin intravenously, as it has been shown to reduce death rates and kidney damage. Some high-risk patients may benefit from taking antibiotics as a preventive measure, but there is a concern about antibiotic resistance. Kidney failure is a major concern for patients with SBP, and it can be reduced by giving the patient albumin intravenously and adding medications if kidney failure develops.

Spontaneous Bacterial Peritonitis, or SBP, is a sudden infection of ascites, which is unusual fluid build-up in the stomach. It is typically found in patients with cirrhosis who are also experiencing ascites.

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