الفهرس 
Acknowledgement
Importance of auditingOnly 14 pages are availabe for public view
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Abstract
Spontaneous bacterial peritonitis (SBP) considered the most common infection in the cirrhotic patient where it represents about 25% of all infections in these patients. It occurs in about 9% of hospitalized cirrhotic patients. Clinical audit aims to compare the current practice to guidelines
In this audit, we reviewed the medical reports of 200 patients admitted in Tropical Medicine and Gastroenterology Department of Assiut University Hospitalin the period from March 2014 till August 2014 .They were diagnosed as SBP in their medical reports comparing it to the recent guidelines.
Two hundred patients, had liver cirrhosis, ascitis, and diagnosed as SBP according to their medical reports such as abdominal pain, fever, deep jaundice and/or disturbed consciousiousness are included in the study were distributed as 84% (168/200) of them were males and 16% (32/200) were females with mean age 48.1 ± 11.2 years .
The collected data included demographic characteristics of the patients as age, sex, site of admission and associated comorbidities and clinical presentation of them. Routine laboratory investigations as LFTs, CBC, PT,INR,urea, and serum creatinine were done to all patients together with diagnostic ascitic fluid samples were taken. All patients were evaluated with abdominal ultrasonography.
The most frequent presentation of those patients was the abdominal pain and/or tenderness and followed by fever,60/200 (30%) and 55/200(27.5%) respectively. Other less frequent presentations were present as diarrhea, jaundice and hepatic encephalopathy were found in 43/200 (21.5%), 37/200 (18.5%) and 5/200(2.5%) patients respectively
Out of those patients, only 30/200 (15%) had actually SBP based on clinical evaluation and confirmed with AF studies. Although, 30 patients had leucocytic count > 250 cell/mm³ in ascitic fluid and yet 21/30 (70 %) patients had no growth in the AF culture. E.coli was the most frequent isolated organism where it was observed in 7/9 patients while S. aureus was isolated in 2/9 patients
The empirical antibiotic therapy was started to all patients based on clinical data only with waiting for the result of AF’s leucocytic count. The use of rapid technique for counting of neutrophil in AF, should be used in patients were suspected to have SBP. If this technique is not available, start antimicrobial therapy fearing of deterioration while waiting AF’s leucocytic count.
The follow for improvement was based on disappearance of fever abdominal pain and/or tenderness. However, the laboratory improvement as second diagnostic paracentesis was not performed, which is recommended for decision of continuing or changing the antibiotic therapy.
Salt free albumin was restricted to those patients with raised renal chemistry to reduce the risk of hepatorenal syndrome. This restriction was attributed to poor socioeconomic causes. It is advisable to:
• Use of rapid technique for counting of leucocytes in the ascitic fluid by using reagent strips to identify the leucocytes in ascitic fluid by detecting their esterase activity asMultistix 8 SG, Nephur, Combur, UriScanor, or Aution. These methods are helpful for rapid management of SBP and reduce risk of complications
• A second diagnostic paracentesis 48 h after antibiotic initiation is a valuable step
• Salt free albumin should be given to those with high risk SBP to reduce risk of deterioration
• Long term prophylaxis for SBP is indicated at time of discharge especially those who have protein level < 15gm/l in the ascitic fluidor with prior attack.
• Re –auditing of SBP after at least 6 months from application of these recommendation, is recommended