Spontaneous Bacterial Peritonitis (SBP)

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

Signs of spontaneous bacterial peritonitis (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 spontaneous bacterial peritonitis (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. Neutrophil count in ascitic fluid of > 250 cells/mcL (0.25 × 10⁹/L) 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 antibioticCefotaxime or another antibiotic

• Albumin for prevention of hepatorenal syndromeAlbumin for prevention of hepatorenal syndrome

If spontaneous bacterial peritonitis (SBP) is diagnosed, an antibiotic such as IV ceftriaxone or cefotaxime (pending Gram stain and culture results) is given for at least 5 days and until ascitic fluid shows If spontaneous bacterial peritonitis (SBP) is diagnosed, an antibiotic such as IV ceftriaxone or cefotaxime (pending Gram stain and culture results) is given for at least 5 days and until ascitic fluid shows< 250 neutrophils/mcL (0.25 × 10⁹/L). For hospital acquired or nosocomial SBP, a regimen of piperacillin/tazobactam and either daptomycin or meropenem should be considered (/L). For hospital acquired or nosocomial SBP, a regimen of piperacillin/tazobactam and either daptomycin or meropenem should be considered (1). Antibiotics increase the chance of survival. Because SBP recurs within a year in up to 70% of patients, prophylactic antibiotics are indicated (2); quinolones (eg, norfloxacin or ciprofloxacin) are most widely used. ); quinolones (eg, norfloxacin or ciprofloxacin) are most widely used.

Patients with SBP should receive 1.5 g/kg albumin (25%) on day 1 and 1 g/kg on day 3 to reduce the risk of Patients with SBP should receive 1.5 g/kg albumin (25%) on day 1 and 1 g/kg on day 3 to reduce the risk ofhepatorenal syndrome; albumin has been shown to improve survival in patients with SBP and cirrhosis (; albumin has been shown to improve survival in patients with SBP and cirrhosis (1, 3). Hypotension can increase the risk of developing hepatorenal syndrome. Thus, nonselective beta blockers should be held in patients with hypotension (mean arterial pressure < 65 mm Hg) and can be resumed after SBP has cleared (1).

Antibiotic prophylaxis in patients with ascites and variceal hemorrhage decreases the risk of SBP, although antibiotic resistance, particularly quinolone resistance, makes prophylaxis less straightforward (1).