2025 Southeastern Residency Conference

Title: 
Evaluation of Quality Measure Outcome Adherence in the Treatment of Spontaneous Bacterial Peritonitis in Patients at a Large Community Hospital

Authors:
Leeann Gowan, Christen Freeman, Doug Carroll

Objective:
Discuss adherence to quality measure outcome set forth by the American Association for the Study of Liver Diseases (AASLD) for the treatment of spontaneous bacterial peritonitis.

Self Assessment Question:
What is the recommended albumin dose patients treated for SBP should receive within 12 hours of the ascitic fluid test result?

Background: 
Spontaneous Bacterial Peritonitis (SBP) is an ascitic fluid infection with an unknown source of origin. This infection is one of many complications resulting from advanced liver cirrhosis and ascites. As recommended by the American Association for the Study of Liver Diseases (AASLD) practice guidance, a diagnostic paracentesis should be performed on all patients with suspected SBP. Management of SBP includes the use of antibiotics and albumin. Empiric IV antibiotics should be initiated in all patients with an ascites polymorphonuclear (PMN) count >250 cells/mm3. 

Furthermore, patients with cirrhosis have an increased risk of worsening liver and renal function from bacterial infections. The appropriateness of treatment of SBP has not been assessed at DCH. Consequently, this is a disease state, that if quality measures are not met, can progress to high rates of mortality and worsening liver and renal function. The purpose of this study was to evaluate percentage adherence to a specific cirrhosis quality measure set forth by the Practice Committee of the AASLD, in the treatment of SBP in patients at DCH Regional Medical Center and Northport Medical Center.

Methods:
This was a retrospective chart review of patients treated for SBP at DCH Regional Medical Center (a large community 583-bed hospital) and Northport Medical Center (a 204-bed community hospital). Patients were included if they were 19 years old or older, had an ICD-10 diagnosis of cirrhosis and ascites and SBP or had an ascitic fluid PMN count >250 cells/mm3. 

A list of patient encounters was generated from the electronic health record (EHR) from May 2021 to July 2024. Patients that were selected for review first, were those with an ICD-10 diagnosis code for SBP, then those with an ascitic fluid white blood cell count (WBC) count. A PMN count was calculated by multiplying the total WBC by the percentage of PMNs in the differential (neutrophils). The primary outcome measure was percentage adherence to meeting all 3 criteria of the guideline recommended quality measure outcome: hospitalized patients with ascites, with an ascitic fluid PMN count of ≥ 250 cells/mm3, should receive: empiric antibiotics and albumin 1.5 g/kg within 12 hours of the ascitic fluid test result and receive albumin 1.0 g/kg on day 3. Secondary outcomes were comparison of results for those with a GI consult, characterization of antibiotic regimen, and patient encounter mortality rate. For the statistical analysis, descriptive statistics were utilized. This study was IRB exempt.

Results:
This study included a total of 40 patients. Overall, there were zero patients that met all 3 criteria of the quality measure outcome. Twenty-eight patients met at least one criteria (70%). Patients with a GI consult overall had improved outcomes. Twelve patients were empirically treated with a 3rd generation cephalosporin (54.5%). Five patients (22.7%) were treated for 5-7 days out of the twenty-two patients only treated for SBP.

Conclusion:
This study observed many ways to improve treatment of SBP at DCH. Areas of improvement include correct albumin dosing, administration of albumin within the 12-hour range, and administration of the second dose of albumin on day 3.