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KJG 72 56
KJG 72 56
2, 56-63
https://doi.org/10.4166/kjg.2018.72.2.56
pISSN 1598-9992 eISSN 2233-6869
REVIEW ARTICLE
Spontaneous bacterial peritonitis (SBP) is defined as bacterial infections that occur in patients with cirrhosis and ascites without any
significant intraperitoneal infection, accounting for approximately 10-30% of bacterial infections in hospitalized patients. SBP devel-
ops in patients with liver cirrhosis because bacterial translocations are increased by changes in the intestinal bacteria and mucosal
barriers. In addition, the decreased host immune response cannot remove the bacteria and their products. The most common cause
of SBP is Gram-negative bacteria, such as Escherichia coli and Klebsiella species, and infections by Gram-positive bacteria are
3
increasing. SBP is diagnosed by the presence of >250 polymorphonuclear leukocyte/mm in ascites after paracentesis. If SBP is
diagnosed, empirical antibiotic therapy should be started immediately. Empirical antibiotic treatment should distinguish between
community acquired infections and nosocomial infections. Cirrhotic patients with gastrointestinal bleeding or low ascitic protein con-
centrations should consider primary prevention and those who recover from SBP should consider secondary prevention. This review
describes the pathophysiology, diagnosis, treatment, and prevention of SBP. (Korean J Gastroenterol 2018;72:56-63)
Received July 12, 2018. Revised July 23, 2018. Accepted July 25, 2018.
CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2018. Korean Society of Gastroenterology.
교신저자: 송도선, 16247, 경기도 수원시 팔달구 중부대로 93, 가톨릭대학교 의과대학 성빈센트병원 내과
Correspondence to: Do Seon Song, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero,
Paldal-gu, Suwon 16247, Korea. Tel: +82-31-249-8204, Fax: +82-31-253-8898, E-mail: dsman@catholic.ac.kr
Financial support: None. Conflict of interest: None.
85
Table 1. Bacteria Causing Spontaneous Bacterial Peritonitis in Korea
References Gram (-) Gram (+)
E.coli (35.8%) Streptococcus species (15.2%)
54
Park et al. (2007) Klebsiella species (15.5%) Staphylococcus species (4.6%)
Aeromonas (4.6%) Enterococcus species (3.3%)
E.coli (32.4%) Enterococcus species (13.0%)
Kim et al. (2016)28 Klebsiella species (19.5%) Staphylococcus species (13.0%)
Pseudomonas (1.3%) Streptococcus species (9.1%)
E.coli (43.2%) Streptococcus species (13.2%)
6
Cheong et al. (2009) Klebsiella species (14.0%) Enterococcus (4.2%)
Aeromonas (4.6%) Staphylococcus aureus (5.1%)
E.coli (48.5%) Streptococcus species (9.1%)
83
Heo et al. (2009) Klebsiella species (22.7%) Staphylococcus species (6.1%)
Aeromonas (6.1%) Enterococcus species (1.5%)
E.coli (25.5%) Streptococcus species (19.1%)
Tsung et al. (2013)84 Klebsiella species (19.1%) Enterococcus species (12.8%)
Enterobacteriaceae (4.3%) Staphylococcus species (6.4%)
dehydrogenate (LDH)가 혈청 내 LDH의 정상 상한치 초과, 구에서 광범위 베타락탐아제(extended spectrum beta-lac-
복수내 포도당 수치가 50 mg/dL 초과인 경우, 적절한 항생제 tamase) 생성 균주가 지역사회 감염 자발성 세균성 복막염
치료 48시간 이후에 시행한 복수천자 검사에서 다형핵 호중 (13-20%)보다 병원내 감염 자발성 세균성 복막염(46-66%)에
54,57-59
구 수가 치료 전보다 감소하지 않는다면 이차성 세균성 복막 서 높았고, 점차 빈도가 증가하는 추세를 보인다. 또한
31 44
염을 의심할 수 있다. 또한 Wu 등 은 복수내 alkaline 병원내 감염 자발성 세균성 복막염은 Enterococcus나 me-
phosphatase >240 U/L 혹은 복수내 carcinoembryonic an- thicillin-resistant Staphylococcus aureus와 같은 다약제
6,28
tigen >5 ng/mL일 경우 민감도 92%, 특이도 88%의 높은 내성 그람 양성균의 빈도가 높다. 병원내 감염 자발성 세균
정확도로 천공에 의한 이차성 세균성 복막염을 진단할 수 있 성 복막염은 지역사회 감염 자발성 세균성 복막염의 경험적
1,6,56,57,60
음을 보여, 복수의 alkaline phosphatase와 carcinoem- 항생제인 3세대 세팔로스포린에 대한 내성률이 높다.
bryonic antigen 농도가 감별에 도움을 줄 수 있겠다. 또한 다약제 내성 균주 및 그람 양성균에 의한 감염 빈도가
높아 지역사회 획득 자발성 세균성 복막염에 비하여 사망률이
7. 치료 높다.
6,59
Fernández 등56은 전향적 연구를 통하여 병원내 감
자발성 세균성 복막염의 발생 장소에 따라 경험적 항생제 염, 장기간의 예방적 항생제 사용, 최근의 베타락탐 항생제
를 적절히 선택하여야 한다. 사용, 최근 입원 병력 등이 다약제 내성균에 의한 자발성 세균
55
성 복막염의 위험인자임을 보였다. Piano 등 은 병원내 감염
1) 지역사회 획득(community acquired) 자발성 세균성 복 자발성 세균성 복막염 환자들을 대상으로 한 무작위 대조군
막염 연구에서 경험적 항생제 치료로서 meropenem+daptomycin
지역사회 획득 자발성 세균성 복막염의 가장 흔한 원인균은 치료가 3세대 세팔로스포린 치료인 ceftazidime보다 좋은 치
Escherichia coli, Klebsiella pneumoniae, Streptococcus이 료 효과를 보였다. 자발성 세균성 복막염의 치료에서 초기 치
며, 이 균주들을 포함한 대부분의 원인균에 효과적인 3세대 료의 실패는 사망률의 증가와 연관되기 때문에 경험적 항생제
55,61
세팔로스포린 계통의 항생제가 권장된다. Cefotaxime은 복 의 선택이 중요하다. 따라서 자발성 세균성 복막염의 경험
45
수내 농도가 매우 높아 복수의 감염 치료에 효과적이다. 자 적 항생제를 선택할 때는 다약제 내성균 감염의 위험인자, 감
62,63
발성 세균성 복막염의 치료에서 cefotaxime 정주 치료는 감 염의 중증도, 지역별 역학을 고려하여 선택하여야 한다.
45-48
염 소실률이 76-98%로 매우 높았고, 5일 치료군과 10일 특히 중증의 감염 상태이거나 다약제 내성균의 위험인자를 가
45
치료군의 치료 효과가 비슷하였다. Ceftriaxone 정주 치료 진 경우에는 carbapenem±glycopeptide 치료를 고려하고,
48-51
도 73-100%의 높은 감염 소실률을 보였으며, cefotaxime 내성 발생률을 줄이기 위하여 48-72시간 후 재평가를 통한
48 62
과 비슷한 치료 효과를 보였다. 따라서 지역사회 획득 자발 하향 조정을 고려하여야 한다.
성 세균성 복막염 환자에서 cefotaxime을 하루에 2 g씩 6-8시
간마다 정주하거나, ceftriaxone을 하루에 1 g씩 12시간마다 3) 알부민
혹은 하루에 2 g씩 정주하는 것이 권장되며, 치료 기간은 자발성 세균성 복막염 환자의 약 30-40%에서 감염의 소실
5-10일이다. 여부와 관계없이 신기능 장애가 발생하게 되며, 신기능 악화
64,65
Amoxicillin-clavulanic acid 정주 치료와 ciprofloxacin 는 사망률의 증가와 연관된다. Sort 등66은 자발성 세균성
정주 치료도 cefotaxime 치료와 비슷한 치료 효과를 보여 3세 복막염 환자에서 cefotaxime만 치료한 군과 cefotaxime과
대 세팔로스포린 치료의 대안으로 고려하여 볼 수도 있겠 알부민(진단 첫날 1.5 g/kg, 3일째 1.0 g/kg) 정주 치료를 같
47,52
다. 위장관 출혈, 신기능 장애, 간성 혼수, 장마비, 쇼크 이 한 군을 전향적으로 비교하였을 때 알부민을 같이 정주한
등의 합병증이 없는 환자에서는 경구 ofloxacin 치료가 cefo- 군에서 사망률(10% vs. 29%)과 신기능 악화(10% vs. 33%)가
53
taxime 정주 치료와 비슷한 효과를 보이기도 하였다. 하지 감소함을 보였다. 하지만 자발성 세균성 복막염의 진단시 혈
만 국내 지역사회 획득 자발성 세균성 복막염 환자에서 fluo- 청 빌리루빈 4 mg/dL 미만, 혈청 크레아티닌 1.0 mg/dL 미
roquinolone 내성이 점차 증가하고 있어 fluoroquinolone의 만인 환자에서는 간신증후군의 발생이 드문 반면에(<8%), 혈
54
경험적 항생제 사용은 주의가 필요하다. 청 빌리루빈 4 mg/dL 이상 혹은 혈청 크레아티닌 1.0 mg/dL
이상인 환자에서는 간신증후군의 발생 위험이 높고(58%) 알
66,67
2) 병원내 감염 자발성 세균성 복막염 부민 치료가 도움이 되었다.
병원에 입원하고 48-72시간 이상 경과한 후 발생한 경우
55,56
병원내 감염 자발성 세균성 복막염이라 정의한다. 국내 연
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