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hep.spontaneous-bacterial-peritonitis.core.v1

Spontaneous Bacterial Peritonitis

hepatologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Fresh hep.* prefix dossier; manifest reuses sbp_workup batch23 scaffold; binds panel.ascites + panel.lft + panel.cbc + panel.renal. Diagnostic criterion: ascitic PMN >=250/mm^3 per AASLD 2021 (PMID 33942342). Empiric ceftriaxone 2g IV daily x 5-7d community-acquired; pip-tazo for nosocomial/MDR risk; meropenem reserved. Sort 1999 albumin criteria (PMID 10432325): Cr >1, BUN >30, or bili >4 -> 1.5 g/kg d1 + 1 g/kg d3 - reduces HRS-AKI and mortality. Secondary prophylaxis lifelong with norfloxacin 400 PO daily OR ciprofloxacin 500 PO daily (norfloxacin USA-discontinued); primary prophylaxis Fernandez 2007 (PMID 17854593) for low-protein ascites + advanced cirrhosis. Runyon criteria embedded for secondary peritonitis differential. NSBB hold during SBP+hypotension/HRS per Baveno VII.

Entry points (5)

  • symptom
    Fever, chills, or abdominal pain in cirrhotic with ascites (AASLD 2021)
    fever_in_cirrhotic_with_ascites
  • symptom
    New or worsening encephalopathy in cirrhotic with ascites (AASLD 2021)
    new_he_in_cirrhotic_with_ascites
  • symptom
    New AKI in cirrhotic with ascites (AASLD 2021)
    aki_in_cirrhotic_with_ascites
  • problem_list
    Any admission of cirrhotic with ascites - mandatory diagnostic paracentesis (AASLD 2021)
    admission_cirrhosis_with_ascites
  • lab_abnormality
    Leukocytosis or lactate elevation in cirrhotic with ascites (AASLD 2021)
    leukocytosis_in_cirrhotic

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Elderly higher mortality; antibiotic dosing adjustment (AASLD 2021)
  • temperaturerequired
    vital • used at CONTEXT
    Fever common; absent in 30% of SBP (AASLD 2021)
  • sbprequired
    vital • used at CONTEXT
    Hypotension - sepsis screen; HRS-AKI risk (AASLD 2021)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia - SIRS/sepsis (AASLD 2021)
  • ascitic_fluid_pmn_countrequired
    lab • used at INITIAL_WORKUP
    PMN >=250/mm^3 = SBP diagnostic per AASLD 2021
  • ascitic_fluid_culturerequired
    lab • used at INITIAL_WORKUP
    Culture-positive SBP vs culture-negative neutrocytic ascites (CNNA); bedside inoculation 10 mL into BCB increases yield (AASLD 2021)
  • ascitic_fluid_total_proteinrequired
    lab • used at INITIAL_WORKUP
    Low protein <1.5 g/dL = high SBP risk; primary prophylaxis criterion (Fernandez 2007 PMID 17854593)
  • ascitic_fluid_albumin_saagrequired
    lab • used at INITIAL_WORKUP
    SAAG >=1.1 confirms portal hypertensive ascites; distinguishes from secondary peritonitis (AASLD 2021)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Sort 1999 criterion (Cr >1.0); HRS-AKI screening; albumin indication (Sort 1999 PMID 10432325)
  • bunrequired
    lab • used at INITIAL_WORKUP
    Sort 1999 criterion (BUN >30); albumin indication (Sort 1999)
  • total_bilirubinrequired
    lab • used at INITIAL_WORKUP
    Sort 1999 criterion (bili >4); albumin indication (Sort 1999)
  • wbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis suggests infection; cirrhotics often blunted response (AASLD 2021)
  • lactate
    lab • used at INITIAL_WORKUP
    Sepsis severity marker (AASLD 2021)
  • inrrequired
    lab • used at INITIAL_WORKUP
    Cirrhosis severity; paracentesis bleeding risk (low) (AASLD 2021)
  • prior_sbp_episoderequired
    history • used at CONTEXT
    Prior SBP - mandatory secondary prophylaxis; recurrence ~70%/yr without (Fernandez 2007)
  • current_antibiotic_use_quinolonerequired
    history • used at CONTEXT
    Resistance pattern - if on prophylaxis ESBL/quinolone-resistant likely (AASLD 2021)
  • recent_hospitalization_or_healthcare_exposurerequired
    history • used at CONTEXT
    Nosocomial vs community - alters empiric coverage (AASLD 2021)
  • beta_blocker_userequired
    history • used at CONTEXT
    Hold NSBB during SBP with hypotension; Baveno VII caution (AASLD 2021)

12-phase flow (12)

  1. 1FRAME
    Confirm SBP scope: cirrhotic with ascites + ascitic PMN >=250/mm^3; distinguish from secondary peritonitis (AASLD 2021)
    inputs: ascitic_fluid_pmn_count
    advance: SBP suspected or confirmed
  2. 2ENTRY
    Recognize fever/abdominal pain/new HE/new AKI in cirrhotic with ascites, or ANY admission with ascites (AASLD 2021)
    advance: one entry trigger present
  3. 3CONTEXT
    Prior SBP, current quinolone/rifaximin use, recent healthcare exposure, NSBB use, allergies (AASLD 2021)
    inputs: age, temperature, sbp, hr, prior_sbp_episode, current_antibiotic_use_quinolone, recent_hospitalization_or_healthcare_exposure, beta_blocker_use
    advance: context captured
  4. 4RED_FLAGS
    Septic shock, severe HE, HRS-AKI, secondary peritonitis (perforation), variceal bleed (AASLD 2021)
    inputs: sbp, creatinine
    advance: red flag escalated or excluded
  5. 5INITIAL_WORKUP
    Diagnostic paracentesis MANDATORY (ALL admissions with ascites + ANY suspicion): cell count + differential, culture (10 mL bedside into BCB), total protein, albumin (SAAG), glucose, LDH, gram stain; concurrent blood cultures x2, urine culture, CBC, BMP, LFTs, INR, lactate (AASLD 2021)
    inputs: ascitic_fluid_pmn_count, ascitic_fluid_culture, ascitic_fluid_total_protein, ascitic_fluid_albumin_saag, creatinine, bun, total_bilirubin, wbc, inr
    actions: panel.lft, panel.cbc, panel.renal
    advance: paracentesis result back
  6. 6BRANCHING_WORKUP
    Runyon criteria for secondary peritonitis (any 2: ascitic glucose <50, LDH > serum upper limit, total protein >1 g/dL, polymicrobial gram stain) - CT abdomen, surgery consult; PMN >=250 with monomicrobial gram-positive = MNB if culture negative; PMN <250 with culture+ = bacterascites (AASLD 2021)
    advance: SBP vs CNNA vs MNB vs secondary peritonitis classified
  7. 7DIFFERENTIAL
    Distinguish SBP from secondary peritonitis (bowel perforation, intra-abdominal abscess), TB peritonitis, malignant ascites with bacterial superinfection, pancreatic ascites (AASLD 2021)
    advance: classification confirmed
  8. 8RISK_STRATIFICATION
    Sort 1999 albumin criteria: Cr >1.0 mg/dL OR BUN >30 mg/dL OR total bilirubin >4 mg/dL = high-risk for HRS-AKI; CLIF-SOFA for septic shock; MELD for transplant priority (Sort 1999; AASLD 2021)
    inputs: creatinine, bun, total_bilirubin
    advance: risk profile assigned
  9. 9TREATMENT
    Empiric ceftriaxone 2 g IV daily x 5-7 days for community-acquired (piperacillin-tazobactam or carbapenem for nosocomial/MDR risk); add albumin 1.5 g/kg day 1 + 1 g/kg day 3 if Sort criteria met; hold NSBB if hypotensive; de-escalate per culture; total course 5-7 days after defervescence (AASLD 2021; Sort 1999)
    inputs: creatinine, bun, total_bilirubin
    advance: antibiotics started + albumin if indicated
  10. 10DISPOSITION
    Floor for stable; ICU for septic shock, HRS-AKI, HE 3-4; transplant evaluation if MELD >=15 or recurrent SBP (AASLD 2021)
    inputs: sbp
    advance: destination locked
  11. 11MONITORING
    Repeat diagnostic paracentesis at 48h ONLY if atypical (suspected resistance, slow response, secondary peritonitis suspicion); daily Cr, Na, K, INR, bilirubin, WBC; daily HE grading; weights (AASLD 2021)
    inputs: creatinine, sodium, wbc
    advance: response documented or escalated
  12. 12FOLLOWUP
    Secondary prophylaxis NORFLOXACIN 400 mg PO daily (or ciprofloxacin 500 mg daily or TMP/SMX DS daily) lifelong or until transplant (Fernandez 2007 PMID 17854593); transplant evaluation; HCC surveillance; hepatology q1-3mo (AASLD 2021)
    advance: prophylaxis started + follow-up scheduled