Spontaneous Bacterial Peritonitis

Definition: Acute infection of the ascitic fluid in a patient with liver disease without another source of infection

Epidemiology: (Runyon 1988, Runyon 1988, Borzio 2001)

  • Incidence
    • 10-25% risk of at least one episode per year
    • 20% risk in those with ascites admitted to the hospital
  • Historically, mortality ~ 50%

Pathophysiology:

  • Not completely understood
  • Increased portal systemic hypertension
    • Causes mucosal edema of the bowel wall
    • Increases transmural migration of enteric organisms into the ascitic fluid
  • Impaired phagocytic function in the liver
  • Impaired immunologic activity in ascitic fluid

Presentation:

  • Classic triad: fever, abdominal pain and increasing ascites. Presence of all three components uncommon
  • Symptoms
    • Fever or chills
    • Abdominal pain
    • Abdominal swelling
    • Fatigue
    • Malaise
  • Signs
    • Abdominal tenderness variable
      • Typically diffuse
      • Can be mild without peritoneal signs
      • Can be severe with rebound and/or guarding
    • Abdominal distension
    • Altered mental status (from hepatic encephalopathy)

Diagnostics:

  • Obtaining an ascitic fluid sample is critical in making the diagnosis
  • Serum blood tests (i.e. WBC, CRP, ESR) are not helpful in making this diagnosis
  • Due to variable presentations and considerable mortality associated with SBP, consideration should be made to perform paracentesis on ALL patients with ascitic fluid who are being admitted (Gaetano 2016)
  • Diagnostic paracentesis (EM: RAP HD)
  • Paracentesis (DrER.tv)

    Ascitic fluid assays

    • Cell count
      • Look for WBC > 250-500 cells/mm3 or neutrophil count > 250 cells/mm3
      • Peritoneal dialysis patients: neutrophil count > 100 cells/mm
    • pH < 7.34 more common in SBP (Wong 2008)
    • Ascitic fluid gram stain (rarely positive) and culture
  • If patient has fever (temp > 100oF) or abdominal pain/tenderness, empiric antibiotics should be given even if neutrophil count < 250 cells/mm3

Management:

  • Antibiotics
    • Most common bacterial causes: E. Coli, S. Pneumoniae, Enterococci
    • 3rd Generation Cephalosporin covers vast majority of cases
      • Ceftriaxone 25 mg/kg up to 1 gm daily
      • Cefotaxime 25 mg/kg up to 1 gm Q8
    • Alternate antibiotic choices
      • Ciprofloxacin 400mg IV BID
      • Levofloxacin 750mg IV daily
      • Piperacillin/Tazobactam 4.5g IV TID
      • Ertapenem 1g IV qD
      • Imipenem/Cilastatin 500mg IV QID
  • Albumin Infusion (Runyon 2012)
    • Recommended by American Association for the Study of Liver Disease (AASLD) in specific subgroups with SBP
      • Presence of any of the following should prompt albumin administration
      • Serum creatinine > 1 mg/dL
      • Blood urea nitrogen (BUN) > 30 mg/dL
      • Total Bilirubin > 4 mg/dL
    • Impact of albumin infusion (Sort 1999)
      • 25% reduction in renal failure
      • 20% reducing n mortality
    • Dose
      • 1.5 grams/kg within 6 hours
      • 1.0 grams/kg on day 3 of treatment
  • Patients with a single episode of SBP should be considered for antibiotic prophylaxis (with norfloxacin, ciprofloxacin or TMP/SMX) (Runyon 2012)

Approach to the Diagnosis and Treatment of SBP (University of Washington)

Take Home Points:

  • SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis
  • An ascites PMN count > 250 cells/mm3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal pain or fever
  • Treatment of SBP is with a 3rd generation cephalosporin with the addition of albumin infusion in any patient meeting AASLD criteria (Cr > 1.0 mg/dL, BUN > 30 mg/dL or Total bilirubin > 4 mg/dL)

For More on this Topic Checkout:

References:

  1. Runyon BA et al. Ascitic fluid analysis in malignancy‐related ascites. Hepatology 1988; 8(5):1104-1109. PMID: 3417231
  2. Runyon BA. Spontaneous bacterial peritonitis: An explosion of information. Hepatology 1988; 8: 171–175. PMID: 3338704
  3. Borzio M et al. Bacterial infection in patients with advanced cirrhosis: a multicentre prospective study. Dig Liver Dis 2001; 33(1): 41-48. PMID: 11303974
  4. Gaetano et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. Journal of Gastroenterology and Hepatology 2016. PMID: 26642977
  5. Wong CL et al. Does this patient have bacterial peritonitis or portal hypertension? How do I perform a paracentesis and analyze the results? JAMA 2008; 299(10):1166-78. PMID: 18334692
  6. Runyon BA. Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012. AASLD Practice Guideline. Link
  7. Sort P et al. Intravenous albumin in patients with cirrhosis and spontaneous bacterial peritonitis. NEJM 1999; 341: 1773-4. PMID: 10432325

Post Peer Reviewed By: Salim Rezaie (Twitter: @srrezaie)

The post Spontaneous Bacterial Peritonitis appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

An Update on Emergency Care in South Africa

As part of the EMSSA/ECCSA conference in Sun City we attended an update on where we are with the Clinical Practice Guidelines (CPG) in the Emergency Care field of South Africa. 
Introducing the topic Michael McCaul (researcher from the Centre for Evidence-based Health Care, Stellenbosch University) gave us an overview of his research on the perceptions of the prehospital industry on the new CPGs in order to strengthen guideline uptake by engaging with decision makers like the HPCSA and National Department of Health (NDoH). 
This was followed with Maryna Venter making a very good case for the need for specilisation of critical care retrieval practitioners. 
Finally Ben van Nugteren gave us an update about where the current CPG updates are and what aspects are holding back possible implementation. 

Strengthening Guideline uptake equipping decision makers for evidence informed policy 

Michael McCaul (Twitter: @MikeMcCaul3)
Michael introduced the background and rationale leading up to his research. The main aim was to explore the perceptions of prehospital providers regarding the dissemination and implementation of the new Clinical Practice Guidelines (CPG) with the South African context. To this end, the results should guide decision makers (like National Department of Health (NDoH) + HPCSA) to better disseminate and implement the new guidelines in a manner that will support the prehospital profession.  This project used implementation research methods, a process where decision makers are involved from the outset, so that the evidence translates to real change in policy, downstream. 
Michael emphasised that this research is a snapshot in time but gives useful themes to help us understand what influenced providers perceived perceptions of the CPGs. He said it’s like understanding what things influence the lens by which prehospital providers view the guidelines and how those perceptions and expectations influence our perceived reality. 
Michael noted that they identified key factors that influenced emergency care providers perceptions of the guidelines: 
  • Emergency Medical Services (EMS) history and different qualifications
  • Previous exposure and experience with CPGs
  • Our expectations
  • How providers were communicated with 
This resulted in three main perceived realities regarding the guidelines:
  1. Providers were excited about the increase in scope and the new opportunities
  2. Concern and disappointment as skills were removed (like intubation) and paramedics felt they lost their identity, or have become redundant
  3. Educational and financial constraints for upskilling were introduced
Michael also highlighted various barriers and facilitators regarding both dissemination and implementation of the guidelines emphasised by prehospital providers:
Lastly, Michael told us about the next steps of this project which is currently underway engaging with national decision makers (NDoH, HPCSA PBEC, Higher education institutions, Industry employers and professional societies like the Emergency Care Society of South Africa) on disseminating the results and doing workshops  to produce implementable solutions. He noted the PBEC are aware of the results and he will be further corresponding with them to strengthen the uptake of the guidelines for all. Michael reiterated that guideline implementation is a long and difficult process and that the first step is to engage stakeholders to be part of the solution. Michael and the team will provide feedback of the stakeholder engagements once that phase has been completed in late 2017, early 2018. 
Michael also presented on the methods and lessons learnt in producing the original CPG as a methodologist for the AFEM core guideline panel. 

Critical Care Transfers (retrieval) Moving Forward

Maryna Venter (ECP ALS paramedic with special interest in neonatal ICU retrieval and transportation)
A move toward specialization in care in SA emergency medical services.

Spaghetti defines Critical Care for EMS: Dynamic comprehensive care of the patient with an acute or chronic illness needing transportation”
The challenge with an improving healthcare system, sicker patients are staying alive for longer, and the management of these patient is getting more and more complex.
Critical Care retrieval is becoming more about escalating care and managing the incredibly sick patient from an already high level of care to another specialised level of care, in a moving environment, with even more challenges than we ever expected.

 
Transportation of the critical care patient MUST be either an upgrade in care, or continuation of care at the level at which the patient is currently managed. If we have all the fancy toys and vents, and pumps and ECMO, who is or should be managing the process? Internationally combination teams appear to be the standard, in Africa, the resources are limited, and a multi-system approach may be impossible.
So who should be doing these transfers? THE NERD… the one who has done the additional work, reading, practical skill acquisition. 

 

 Maryna reiterated that “load and go” for these incredibly sick patients is probably NOT the best approach to management, as the critical care patient has multi-faceted needs.
Equipment must be specialised to account for the sick patient – we cannot be downgrading the level of care for transportation to upgrade for additional level of care in another facility.

 

So the bottom line for retrieval and out of hospital critical care in South Africa is clearly going to be a challenge, change is inevitable and in doing so we are going to have to challenge some established practice. Change is coming, it’s going to be good, but at times it will be tough.

 

Out-of-hospital Clinical Practice Guideline

Ben Van Nugteren discussed the current process on the Clinical Practice Guidelines.
Disclaimer The discussion and update provided today is based on his capacity as the Chair of the Clinical Advisory Committee at the PBEC, and cannot be viewed as the full Board’s view. 
Misperception 
Ben gave some context to the Clinical Practice Guidelines (CPGs). There was an incorrect perception that the CPGs were leaked” to only certain emergency care providers. This was an unfortunate perception as the CPGs were circulated to employers, professional bodies and societies, educational institutions and via the PBEC website. Unfortunately, as a result of an administrative hurdle, the research methodology section was not uploaded with the actual CPGs. As a matter of interest by law, formal communication to registered professionals needs to occur via registered post, and the PBEC realised the time and costs linked to such an approach would not be feasible. With the modernisation of the PBEC business processes, this arduous task will hopefully be streamlined going forward. There was never an intention to hide’ the document from anyone.
Commentary
This was the first time the PBEC had undertaken a task like this inviting open comment via email, once again demonstrating the PBEC’s willingness to receive feedback from prehospital providers.  Approximately 90 comments were made, whereupon the PBEC categorised the comments according to themes (i.e. education related, personal views/expressions, implementation etc). Many of the comments centered around the fact that the identity of providers was linked to their list of capabilities. The PBEC sees this as an important factor, but it cannot be seen in isolation. The question of professional identity linked with an endotracheal tube is not in the public’s interest, but rather, whether or not that endotracheal tube is good for the member of public”. To date, that question remains unanswered, globally. Simply put, the test is, is the intervention good for the member of the public, not whether there is skill proficiency”. 
Implementation (Not Yet – Too much redtape)
Regarding implementation, the PBEC has engaged with universities regarding the implementation of the CPGs within the curriculum of the programmes offered within that space. This is easily done as part of an already existing evidence-based approach to clinical education. Regarding CPG implementation for the other tiers of qualification, regulatory bodies such as the Medicines Control Council are closely working with the PBEC to determine a controlled, legal process leading to implementation. All of these changes in practice require regulatory grounding. An important question that the PBEC is pondering what level of responsibility, accountability and ownership do independently registered professionals have within this CPG process.
In closing, the PBEC stressed that the CPG implementation can only be successfully implemented in the presence of robust emergency service regulations.
 

This post was co-created during the EMSSA/ECSSA conference that took place in Sun City.

The post An Update on Emergency Care in South Africa appeared first on #badEM.