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Spontaneous Bacterial Peritonitis (SBP)

By Steven K. Herrine, MD, Professor of Medicine, Division of Gastroenterology and Hepatology, and Vice Dean for Academic Affairs, Sidney Kimmel Medical College at Thomas Jefferson University

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Spontaneous bacterial peritonitis (SBP) is infection of ascitic fluid without an apparent source. Manifestations may include fever, malaise, and symptoms of ascites and worsening hepatic failure. Diagnosis is by examination of ascitic fluid. Treatment is with cefotaxime or another antibiotic.

SBP is particularly common in cirrhotic ascites. This infection can cause serious sequelae or death. The most common bacteria causing SBP are gram-negative Escherichia coli and Klebsiella pneumoniae and gram-positive Streptococcus pneumoniae; usually only a single organism is involved.

Symptoms and Signs

Patients have symptoms and signs of ascites. Discomfort is usually present; it typically is diffuse, constant, and mild to moderate in severity.

Signs of SBP may include fever, malaise, encephalopathy, worsening hepatic failure, and unexplained clinical deterioration. Peritoneal signs (eg, abdominal tenderness and rebound) are present but may be somewhat diminished by the presence of ascitic fluid.


  • Diagnostic paracentesis

Clinical diagnosis of SBP can be difficult; diagnosis requires a high index of suspicion and liberal use of diagnostic paracentesis, including culture. Transferring ascitic fluid to blood culture media before incubation increases the sensitivity of culture to almost 70%. PMN count of > 250 cells/μL is diagnostic of SBP. Blood cultures are also indicated. Because SBP usually results from a single organism, finding mixed flora on culture suggests a perforated abdominal viscus or contaminated specimen.


  • Cefotaxime or another antibiotic

If SBP is diagnosed, an antibiotic such as cefotaxime 2 g IV q 4 to 8 h (pending Gram stain and culture results) is given for at least 5 days and until ascitic fluid shows < 250 PMNs/μL. Antibiotics increase the chance of survival. Because SBP recurs within a year in up to 70% of patients, prophylactic antibiotics are indicated; quinolones (eg, norfloxacin 400 mg po once/day) are most widely used.

Antibiotic prophylaxis in ascitic patients with variceal hemorrhage decreases the risk of SBP.