Since the first description of subacute bacterial peritonitis over 20 years ago, the associated mortality rate has markedly decreased. However, subacute bacterial peritonitis is still fatal in 30 to 40 percent of cases. Moreover, the diagnosis can be difficult to make, given the paucity of signs and symptoms in a significant number of patients. Gilbert and Kamath review the most recent studies of subacute bacterial peritonitis and propose algorithmic approaches for the diagnosis and treatment of patients with this disorder.
Subacute bacterial peritonitis is primarily a disease of patients who have endstage liver disease and ascites. Prevalence rates of subacute bacterial peritonitis as high as 31 percent have been prospectively ascertained in hospitalized patients with cirrhosis. Although fever, abdominal pain and ascites are seen in the majority of patients, ascites is not always clinically obvious and up to 10 percent of patients with proven subacute bacterial peritonitis are completely asymptomatic. An onset or worsening of encephalopathy occurs in about 60 percent of cases, and rebound tenderness may be present in 50 percent of cases. Abdominal findings may be absent in 50 percent of cases.
Ascitic fluid polymorphonuclear cell count, obtained by paracentesis, is the single best predictor of a diagnosis of subacute bacterial peritonitis. The authors propose that patients with polymorphonuclear cell counts greater than 500 per [mm.sup.3] should be considered as having subacute bacterial peritonitis regardless of symptoms. Patients with counts of 250 to 500 cells per [mm.sup.3] should be treated presumptively if they are symptomatic; patients who do not have symptoms of subacute bacterial peritonitis should undergo repeat paracentesis in 24 to 48 hours.
Gram-negative enteric bacteria are the causative organism in the majority of cases of subacute bacterial peritonitis. The authors note that traditional therapy with ampicillin and an aminoglycoside has been associated with high rates of nephrotoxicity. They have developed an algorithm that recommends empiric treatment with cefotaxime. Intravenous treatment should be continued for five to seven days after the polymorphonuclear cell count is noted to be less than 250 per [mm.sup.3].
Recurrence rates for subacute bacterial peritonitis have been reported to be as high as 68 percent. Secondary prophylaxis with daily norfloxacin is noted by the authors to be effective in reducing recurrences of subacute bacterial peritonitis, but it has not been successful in reducing overall mortality. (Mayo Clinic Proceedings, April 1995, vol. 70, p. 365.)
COPYRIGHT 1995 American Academy of Family Physicians
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