P114 Spontaneous bacterial peritonitis prophylaxis in a day case paracentesis unit: a quality improvement project

<h3>Introduction</h3> Spontaneous Bacterial Peritonitis (SBP) is a common complication of ascites and carries a 20–40% mortality rate.¹Patients with ascitic protein count &lt;15g/L have higher risks of developing SBP and BSG guidance states that these patients should be offered primary antibiotic prophylaxis.² The same guidance also recommends post-SBP secondary prophylaxis. Patients requiring regular paracentesis are often managed in nurse-led day case units, relieving pressure on overrun acute inpatient and emergency services. These patients may consequently become less visible to their responsible clinicians and as a result, may not experience optimal medical supervision. We investigated the adherence to BSG guidelines on the prevention and treatment of SBP in our day case paracentesis unit. <h3>Methods</h3> The electronic clinical records of all patients attending for day case paracentesis in November 2023 were interrogated including clinic letters, MDT discussions, medication review and ascitic fluid analysis. Clinical events over the subsequent four months were also investigated. <h3>Results</h3> 25 patient underwent large volume paracentesis during the study period. Most were male (n=16, 64%) and alcohol was the most frequent causative aetiology (n=19, 76%). Two patients had evidence of prior SBP (8%); neither were taking antibiotic prophylaxis. One current episode of possible SBP was found during the study period. This was a positive staphylococcus aureus culture without raised white cell counts or clinical features of SBP; while felt clinically to be a skin contaminant, this was treated with antibiotics and no secondary prophylaxis was prescribed. Seven cases of ascitic protein &lt;15g/L were found (28%); no prophylaxis was prescribed. Five ascitic protein requests were rejected by the lab (205%) as either incorrect/no samples received. Of the entire cohort, 3 patients developed ne novo SBP during the 4 month follow up period (12%, one had a prior low ascitic protein level, p=1.000), 6 were referred to a tertiary liver centre (24%) and six patients died (24%). 5 patients (20%) had evidence of an MDT discussion regarding their medical care. <h3>Discussion</h3> We have demonstrated a lack of adherence to guidelines for SBP treatment and prophylaxis at our centre, and reinforced the poor prognosis associated with intractable ascites requiring regular paracentesis. It is vital that such patients remain under close supervision, with MDT involvement and advance decision making. Our centre has since made substantial changes to how such patients are managed including discussing all patients at a specialist MDT. A re-audit of adherence and outcomes is ongoing. <h3>References</h3> NICE guidelines NG50. Cirrhosis in over 16s: assessment and management. Available from https://www.nice.org.uk/guidance/NG50. (Last accessed 1/6/2024). Aithal GP, Palaniyappan N, China L,<i> et al</i>. Guidelines on the management of ascites in cirrhosis. <i>Gut</i>. 2021 Jan;<b>70</b>(1):9–29.