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PTH-016 Diagnosis And Management Of Spontaneous Bacterial Peritonitis: Is There A Need For An Urgent Update Of National Guidelines?
  1. A Goel,
  2. S Murugesan,
  3. MT Hendrickse
  1. Gastroenterology, Blackpool Teaching Hospitals NHS Trust, Blackpool, UK

Abstract

Introduction Spontaneous Bacterial Peritonitis (SBP) is a frequent and serious complication in cirrhotic patients with ascitis. Clinical guidelines have been published by the BSG, EASL and AASLD for the diagnosis and management of SBP. We carried out a survey of current practice in the diagnosis and management of SBP in the North West of England.

Methods Survey questionnaires were sent to the Hepatology leads of NHS hospital trusts in the North West of England.

Results 11 responses from a total of 18 hospitals are included in this analysis. Ascitic fluid total white cell count (WCC) is estimated in all hospitals but only 6 (54.5%) estimate neutrophil count in addition. However only 5 trusts out of these 6 base the diagnosis of SBP on neutrophil count > 250 /mm3(0.25 × 109 /L) which is in line with the recomendations of the above guidelines. Remaining use WCC >250 /mm3 (0.25 × 109 /L) as the criteria to diagnose SBP. Bedside inoculation of ascitic fluid for culture and sensitivity is practiced in most hospitals (10 of 11, 90.9%). First line antibiotic regimes used are listed in Table 1.

All hospitals offer secondary prophylaxis, ciprofloxacin being the most commonly used (8/11, 72.7%). Septrin 960 mg o.d. is recommended in 2 hospitals (18.2%) and a choice of ciprofloxacin, septrin or rifaximin in another. The dose of ciprofloxacin used was also varied – 500 mgs o.d. in 6 hospitals (75%), 250 mgs o.d. in 1 (12.5%) and 250 mgs weekly in 1 hospital (12.5%).

Primary prophylaxis is offered in only 2 hospitals (18.2%) based on ascitic fluid albumin concentration of <20 g/L in one or <10 g/L in those patients awaiting orthotropic liver transplant with no prior history of clostridium difficile infection in the other hospital.

Abstract PTH-016 Table 1

Recommended first line antibiotic for Treatment of SBP (number of hospitals, percentage)

Conclusion There is wide variation in practice in hospitals in the North West of England despite national and international guidelines. Varied criteria are used to diagnose SBP with fewer hospitals using ascitic neutrophil count which may lead to overdiagnosis and over use of antibiotics. There is a trend towards using tazocin and augmentin as first line antibiotics in the management of SBP even though the evidence is currently unclear. This probably reflects the underlying fear of Clostridium difficile infection associated with the use of quinolones and cephalosporins. Septrin is sparsely used for secondary prophylaxis despite being the preferred antibiotic of choice in regional liver transplant centre. An update of national guidelines regarding management of SBP including primary prophylaxis is urgently required.

Disclosure of Interest None Declared.

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