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1 1 Treatment and Prophylaxis of Spontaneous Bacterial Peritonitis (1); (2), (3). (1) (2) (3) :, :,
2 2 Clinical Question ,.,,.,...
3 3. CT..,.
4 4? SBP? SBP.
5 5 Clinical Question SBP? SBP,?
6 6 SBP (Spontaneous Bacterial Peritonitis or primary peritonitis). and/or > 250/ul.. Runyon, et al. Clin Infect Dis. 1998;27:
7 7
8 8 : SBP 3, GPC
9 9 SBP Bacterial Translocation SBP Modified from Arroyo, et al. Infection;1994:22(3):
10 10 SBP. > > >,. ( ). ( ). Levison, et al. Chapter 76. Peritonitis and Intraperitoneal Abscess. Mandell, Douglas, and Bennett s Principles and Practice pf Infectious Diseases. 8th edition New York. Elsevier.
11 SBP 1 g/dl (1) SBP : HR 3.43 [95%CI ] (2), -1 69% (3) (4) PPI : HR 1.72 [ ] (2) 1. Runyon. Gastroenterology. 1986;91(6): Dam et al. Hepatology. 2016;64(4): Tito, et al. Hepatology. 1988;8(1): Rimola, et al. Hepatology. 1985;5(3):
12 SBP & (1).,,,, etc (2). 46% (2). 30%, (3). (4). SBP 60% (5). 1. Hoefs, et al. Hepatology. 1982;2: Carey, et al. Am J Gastroenterol. 1986;81: Runyon, et al. Hepatology. 1990;12: Runyon, et al. Hepatology. 2013;57: Chinnock, et al. J Emerg Med. 2013;44(5):
13 SBP,,. :,,,TP, LDH, Glc (1). Alb (SAAG), Amy ( ) (1) : 43% (2). 10 ml : 93%(2). (3). 1. Akriviadis, et al. Gastroenterology. 1990;98(1): Runyon, et al. Gastroenterology. 1988;95(5): Runyon, et al. Clin Microbiol. 1990;24:
14 SBP : : 50% (1) : 100% (2). (, Level A.) (3) 1. Nousbaum, et al. Hematology. 2007;45: Meddler, et al. J Hepatol. 2010;53: ( 2 ). 14
15 15 SBP 239 SBP. :12 or Kim, et al. Am J Gastroenterol Sep;109(9):
16 16 SBP : Classic SBP: 250/ul. Culture-negative neutrocytic ascites (CNNA): 250/ul. Monomicrobial non-neutrocytic bacterascites (MNB): 250/ul. Modified from Bhuva, et al. Am J Med. 1994;97:
17 17 SBP : CNNA Culture-negative neutrocytic ascites (CNNA): 250/ul. SBP 250/ul, SBP (1,2). classic SBP CNNA (3). 1. Runyon, et al. Management of Adult Patients with Asictes Due To Cirrhosis: Update AASLD practice guideline.. Hepatology. 2013;57(4): Runyon, Hoefs. Hepatology. 1984;4(6): Pelletier, et al. J Hepatic. 1990;10(3):327.
18 SBP : MNB Monomicrobial non-neutrocytic bacterascites (MNB): 250/ul., 62% (1). MNB,, (2, 3, 4)., (2, 3, 4). 1. Runyon. Hepatology. 1990;12: Pelletier, et al. Hepatology. 1991;14(1): Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: Update Hepatology. 2013;57(4): Levison, et al. Chapter 76. Peritonitis and Intraperitoneal Abscess. Mandell, Douglas, and Bennett s Principles and Practice pf Infectious Diseases. 8th edition New York. Elsevier. 18
19 SBP : MNB MNB (i.e. ), SBP classic SBP (1, 2, 3, 4). (3, 4). 1. Runyon. Hepatology. 1990;12: Pelletier, et al. Hepatology. 1991;14(1): Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: Update Hepatology. 2013;57(4): Levison, et al. Chapter 76. Peritonitis and Intraperitoneal Abscess. Mandell, Douglas, and Bennett s Principles and Practice pf Infectious Diseases. 8th edition New York. Elsevier. 19
20 20 SBP 250/ul? SBP? YES NO YES classic SBP CNNA de-escalation empiric therapy 5 5. NO SBP YES SBP YES MNB 250/ul or? NO? NO Runyon, et al. Management of Adult Patients with Asictes Due To Cirrhosis: Update AASLD practice guideline. Hepatology. 2013;57(4):1651. YES SBP NO
21 21 2,.,. SBP,. Soriano, et al. J Hepatic. 2010;52(1):39-44.
22 /ul. /ul. 2., (polymicrobial pattern. ) : 1 g/dl, LDH, 50 mg/dl 2. and/or 3. 96% %, 90%. 2, 85% CT. Soriano, et al. J Hepatic. 2010;52(1):39-44.
23 23 2 CEA 5 ng/ml ALP 240 U/L : 2 ( 92%, 88%). 2. Wu, et al. J Hepatic. 2001;34:
24 2 250/ul ( 96%) (1). 1. polymicrobial pattern ( 50%) (1): 1 g/dl, LDH, 50 mg/dl. YES NO? SBP YES NO NO? YES. (1) Soriano, et al. J Hepatic. 2010;52(1): (2) Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: Update Hepatology. 2013;57(4):1651. (3) Runyon, et al. Spontaneous bacterial peritonitis in adults: Diagnosis. UpToDate. updated on 17 Aug, UpToDate, Inc. (4) Akriviadis, et al. Gastroenterology 1990;98: ? YES NO SBP
25 25 SBP : SBP.,,., >250/ul SBP., 48. Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: Update Hepatology. 2013;57(4):1651.
26 SBP β (,, ) (1) 1 g q24 hr, 2 g q8hr (2). 500 mg IV/PO q24hr (2). 1.5 kg/day. 1 g/kg 3 (1, 2). 5-7 (1,2). de-escalation ( ). 1. Mandofer, et al. Gastroenterology Jun;146: Carpenter. Peritonitis, Spontaneous Bacterial & Secondary. The Johns Hopkins POC-IT ABX Guide Jones and Bartlett. 26
27 27 SBP β β. - -, - - Mondefer, et al. Gastroenterology Jun;146(7):
28 28 SBP :, (1) g/kg, g/kg (1). Cre 1 mg/dl, BUN 30 mg/dl, or T-Bil 4.0 mg/dl (2). (3). 1. Sort, et al. N Engl J Med. 199;341: Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: 3. Update Hepatology. 2013;57(4): Sigal. et al. Gut. 2007;56:
29 29 SBP : ( 2 = 100%, Level A) (1). 60 kg 1.5 g/kg = 90 g (25%Alb 50 ml, 7 ). : SBP ( 1, Level A) (2) ( 2 ) ( 1 )
30 30 (1).,, β,, (Class IIa, Level C) (1) (2). 1. Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: Update Hepatology. 2013;57(4): Akriviadis, et al. Gastroenterology 1990;98:
31 31 (expert opinion) 5, - 250/ul :. - : /ul : 48,. Runyon, et al. Spontaneous bacterial peritonitis in adults: Treatment and Prophylaxis. UpToDate. updated on 4 Jan, UpToDate, Inc.
32 32 SBP (1) % (2, 3). 1 69%, 1 70% (4). SBP (5). 1. Runyon. Clin Infect Dis. 1998;27: Navasa, et al. Gastroenterology. 1996;111(4): Runyon, et al. Gastroenterology. 1991;100(6): Tito, et al. Hepatology. 1988;8: Runyon, et al. Spontaneous bacterial peritonitis in adults: Treatment and Prophylaxis. UpToDate. updated on 4 Jan, UpToDate, Inc.
33 33 Clinical Question 2 65 C.. SBP,?
34 34 SBP SBP, (1)., (2). 1. Cohen, et al. Cochrane Databese of Systematic Reviews. 2009, Issue Ariza, et al. J Hepatol, 2012;56:825.
35 35 SBP (1) 1 2 (2).. UTI SBP. PPI. 1. Runyon, et al. Spontaneous bacterial peritonitis in adults: Treatment and Prophylaxis. UpToDate. updated on 4 Jan, UpToDate, Inc. 2. Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: Update Hepatology. 2013;57(4):1651.
36 AASLD : SBP :1 (Class I, Level A) (1). : 32%, 9.1% (2) 1. Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: Update Hepatology. 2013;57(4): Bernard. et al. Hepatology. 1999;29:
37 37 AASLD meta-analysis (1). gastrointestinal bleeding, (2). (3). 1. Bernard. et al. Hepatology. 1999;29: Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: Update Hepatology. 2013;57(4): ( 2 ).
38 38 AASLD : SBP :1 <1.5 g/dl (Class I, Level A) (1, 2). a. (Cre > 1.2 mg/dl, BUN > 25 mg/dl or Na < 130 me/l) b. (Child-Pugh score 9 T-Bil 3 mg/dl) : SBP OR 0.18 [95%CI ], OR 0.60 [ ] (2). 1. Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: Update Hepatology. 2013;57(4): Loomba, et al. Clin Gastro Hep. 2009;7(4):
39 39 SBP 1 : RCT P: <1.5 g/dl + I: po C: placebo O: SBP,, SBP 7% 61% 1 Fernandez, et al. Gastroenterology. 2007;133:
![40 SBP 1 : systematic review P: <1.5 g/dl 4 RCT I: C: vs. odds ratio [95% CI] SBP 0.18 [0.09-0.](/docs-images/90/104364839/images/40-1.jpg "35] 0.18 [0.10-0.32] 0.60 [0.37-0.97] O: SBP,, Loomba, et al. Clin Gastro Hep.")
40 40 SBP 1 : systematic review P: <1.5 g/dl 4 RCT I: C: vs. odds ratio [95% CI] SBP 0.18 [ ] 0.18 [ ] 0.60 [ ] O: SBP,, Loomba, et al. Clin Gastro Hep. 2009;7(4):
41 SBP 1 : Cochrane Review Cohen, et al. Cochrane Databese of Systematic Reviews. 2009, 15;(2):CD
42 42 AASLD : SBP :2 SBP (Class I, Level A) (1). : 1 20%, 68% (2) 1. Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: Update Hepatology. 2013;57(4): Gines, et al. Hepatology. 1990;12(4 Pt 1):716.
43 43 SBP : : 1 g q24 hr 7 (1). : 400 mg po, ST DS po. - (Class IIb, Level C) (1, 2). - (expert opinion) (3). 1. Runyon, et al. AASLD practice guideline. Management of Adult Patients with Asictes Due To Cirrhosis: Update Hepatology. 2013;57(4): Terg, et al. Hepatology. 1996;24: 455A. 3. Runyon, et al. Spontaneous bacterial peritonitis in adults: Treatment and Prophylaxis. UpToDate. updated on 4 Jan, UpToDate, Inc.
44 44 ( 2 = 100%, Level A). < 1.5 g/dl 1, ( 2, Level A). SBP 2, ( 2, Level A) ( 2 ).
45 45 SBP : + /. :. : 3, : SBP. 3.. : ST,.
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CHEMOTHERAPY AUG. 1982 VOL. 30 NO. 8 CHEMOTHERAPY Fig.1 Relation between various-closis of cefazolin and detection rate of organisms in heart blood of dying mice with E. coli and P. aeruginosa infection
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日本呼吸器学会雑誌第44巻第10号
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Study on Clinical Factors Affecting the Fungal Culture Test - Relevance of Dry Mouth - Yoshiko YAMAMURA, Yukihiro MOMOTA, Hideyuki TAKANO, Koichi KANI, Katsumi MOTEGI, Fumihiro MATSUMOTO, Masayuki AZUMA
日本呼吸器学会雑誌第47巻第6号
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clinical question 2015 年 12 月 14 日 J Hospitalist Network 肝硬変による 難治性腹水の治療 筑波総合診療グループ筑波メディカルセンター病院総合診療科作成者 : 髙橋弘樹監修 : 廣瀬由美 分野 : 消化器テーマ : 治療 現病歴 症例 :66 歳女性 61 歳時から原発性胆汁性肝硬変のため消化器内科通院中 64 歳時から肝性脳症 大量腹水貯留で複数回入院歴あり
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Key words: bacterial meningitis, Haemophilus influenzae type b, Streptococcus pneumoniae, rapid diagnosis, childhood
Key words: bacterial meningitis, Haemophilus influenzae type b, Streptococcus pneumoniae, rapid diagnosis, childhood Fig.1 Distribution of the cases with bacterial meningitis by age and pathogens Chiba