Spontaneous Bacterial Peritonitis

As I mentioned in my introductory blog, one thing I will be doing is sharing with you, the reader, cases that I see clinically at work. Working at a University Hospital, I have the opportunity to see and learn about a wide array of pathologies. I got the idea from an article I read that said you should always carry a 3X5 card in your shirt pocket when in clinic. If you see a patient with a particular disease that you’ve never heard of or know nothing about, jot it down, look it up, and learn about it. Add your findings to the 3X5 card and store them in a box, much like you’d use to store recipes in. I thought this would be a fun way of learning something each week that will surely translate into my training as a PA, so I’m now doing that and want to share with my followers. At the end of the year, I will have assembled a box full of new knowledge that I can refer back to at points along the way.

On my job, I get to round with interns, medical students, residents, fellows and attending physician’s in the ICU. This week there was a patient that had SBP. Not knowing what that was, I took the opportunity to ask a resident that I have befriended. After telling me a little about SBP, I pulled an article and will share with you the highlights of Spontaneous Bacterial Peritonitis (SBP).

Introduction:

SBP is an infection of ascetic fluid without a definitive abdominal source that can be treated surgically. SBT is common in cirrhosis of the liver with concomitant ascites. Patients that survive such an infection have 1 and 2 year mortality rates of 70% and 80% respectively, and the recurrence rate within a year of the initial infection, ranges from 40-70%.

Pathogenesis:

The pathogenesis of SBT is caused by a prolonged bacteremia, secondary to a compromised host, intrahepatic shunting, colonized blood, and ineffective antibiotics. Predictors of SBT are an increased bilirubin >2.5mg/dL and low ascetic protein level < 1g/dL. The typical offending pathogens are gram-negative rods and streptococci.

Signs and symptoms:
Some common signs and symptoms that are seen with SBT are listed here

• Fever, abdominal tenderness
• GI bleeding, nausea & vomiting
•  Chills, change in mental status
• Cytologic analysis of fluid obtained by paracentesis is the best way to assess and identify SBP (see link for procedure) https://www.youtube.com/watch?v=zyvHGmigvD0
• The best information is relative to the neutrophil level ---> 250-500 cells/mL
• pH and lactate measurement of fluid is not particularly helpful or useful

Primary SBP vs. Secondary SBP:

Primary SBT has the following:

• monomicrobic
•  PMN’s >250 cells/mm³
• Gram negative rods (GNR’s)

Secondary SBP:

• Total protein >1g/dL
• Glucose < 50mg/dL
•  LDH > upper limits of normal (ULN)
• PMN’s > 250 cells/mm³

Treatment:

The treatment for SBT is typically pharmacologic in nature and the antibiotics used will depend on local epidemiologic patterns. Empirical antibiotic s are recommended. Several antibiotics were mentioned in the article I read, but two of the common ones were Ceftaximine and Ceftriaxone. After the initial paracentsis, it is recommended that a second diagnostic paracentesis be done 48 hours later, in order to assess the efficacy of the antibiotics being used for treatment. The literature says that is there is not a 25% or greater improvement in the decrease of PMN’s. If you aren’t able to reduce the nutrophile count by 25%, it is seen as a failure of treatment.

Albumin:

The single largest predictor of death in SBP is renal failure. With that, the question of Albumin administration has to be asked. Who gets Albumin?

•  serum Bilirubin > 4mg/dL
• serum Creatinine > 1mg/dL
• BUN > 30mL/dL

It should also be mentioned that the dose for Albumin be limited to 100 g/dose. If the SBP is complicated, then Albumin should not be administered. If renal function is NOT compromised and the is NO encephalopathy, then Albumin should not be administered

Prophylaxis:

Prophylactic treatement should be reserved for patients at greates risk for SBP. So, who is at greatest risk for the development of SBT?

•  Past history SBP
• Upper GI bleed
• Low total protein level in ascetic fluid

Reference:

1. Alaniz, C., Regal, R.E. Spontaneous Bacterial Peritonitis. P.T. 2009 Apr; 34(4) 204-210.

About me

My name is Bryan and I have decided to create a blog about my life as a physician assistant (PA) student. By having this blog, it is my hope that you'll be able to see what it's like to be a PA student in training, and also gain some insight to the struggles a PA student WILL face along the way and what I do to overcome them. I also want to share with you what I am learning about each week.

A little about me: I've been a registered respiratory therapist (RRT) for 19 years now. I wanted to
be a PA shortly after beginning my career, when I found myself working with some PA's in the emergency room and on the wards. I've always admired their training, autonomy, and professionalism. Another appealing aspect of becoming a PA has been the length of training required. In 27 months of rigorous didactic and clinical training, I could significantly expand my autonomy, increase my knowledge of medicine, and become an key member of the patient's care team. For me, it was the next obvious step in my love of medicine and patients, and to expand my role on the team.

After being accepted and excited to begin one of the top PA programs in our nation, I began PA school in the Fall of 2015. While, as a non-traditional student (I'm 47), I found it difficult and challenging being back in the classroom, I very much loved being neck deep in the curriculum of the first semester and learning from, what I consider, to be the best and brightest instructors in the world. http://grad-schools.usnews.rankingsandreviews.com/best-graduate-schools/top-health-schools/physician-assistant-rankings However, about halfway through the first semester of school, my mother was unexpectedly faced with some medical issues. As part of her treatment, she would require back surgery. The first surgery didn't correct the problem as the doctor had hoped and in fact, it seemed to make matters worse.

Two days after the initial surgery, my mother would once again undergo back surgery. After the second surgery she improved minimally, and was discharged home to recover and later begin physical therapy. For her the pain was unbearable during her recovery at home, but she tired to press on. Unfortunately, while recovering at home, she fell in the bathroom while using her walker and broke her leg. It was with this setback that I made the tough decision to withdraw from school, in order to return home to help care for my mother. As it turned out, she would not have to have surgery for the broken leg, but she would have to wear a cast until it healed. To add to that, it was decided that she'd need a third back surgery (once the leg healed enough) to correct the compression of spinal nerves that was causing her such great pain and loss of ability to walk. In February of 2016, my mother underwent her third surgery to correct the problem. The procedure is called an ALIF procedure https://www.youtube.com/watch?v=HXtKKB6zEhM and thus far has brought much pain relief, along with regaining 80% use of her lower limbs.

Since withdrawing from school in 2015, I have been accepted back into the same program for the Fall of 2017. I continue to work as a respiratory therapist 3 and 4 days a week and during my off time, I study anatomy, physiology, pathology, and clinical medicine books on my own, in preparation for my return to the rigor of coursework to come; better known as "the thunder dome" of PA school. After getting a stiff drink from the fire hydrant of first semester training, I'd be foolish not to spend my time wisely, getting ready for the grind that will soon be here. To that end, I hope you'll follow along as I spend the next year getting ready and even when I officially start the program. As I blog, I'll be sharing information on textbooks, websites, and different cases I find interesting while working in the University Medical setting during the year proceeding re-entry to PA school.

Thanks for following along and please feel free to contact me with questions or comments. While my goal is to have a weekly post, I suspect that will wax and wane when school begins again, but I think having a blog to document and share my journey will be well worth it.

Take care!
Bryan