What are the diagnostic criteria for spontaneous bacterial peritonitis (SBP)?

From the Guidelines

To diagnose spontaneous bacterial peritonitis (SBP), a diagnostic paracentesis should be performed and the ascitic fluid analyzed for a neutrophil count ≥250 cells/mm³ without an intra-abdominal source of infection, as recommended by the most recent guidelines 1. The diagnosis of SBP is crucial in cirrhotic patients with ascites, as it can lead to high morbidity and mortality if left untreated.

• The ascitic fluid should be analyzed for neutrophil count, and a count ≥250 cells/mm³ is diagnostic of SBP 1.
• Ascitic fluid culture with bedside inoculation of blood culture bottles should be performed to guide the choice of antibiotic treatment when SBP is suspected 1.
• Immediate empirical antibiotic therapy should be determined with due consideration of the context of SBP, severity of infection, and local bacterial resistance profile 1. Some key points to consider in the management of SBP include:
• The use of third-generation cephalosporins, such as cefotaxime, as empirical antibiotic therapy 2.
• The importance of considering local resistance patterns and adjusting antibiotic therapy accordingly 2.
• The need for a second diagnostic paracentesis at 48 hours from the start of treatment to check the efficacy of antibiotic therapy in patients who have an apparently inadequate response 1. Treatment should begin immediately with a third-generation cephalosporin, such as cefotaxime, and the choice of antibiotic should be guided by local resistance patterns and protocol 1. For patients with renal dysfunction, adding albumin to prevent hepatorenal syndrome may be considered 2. Prophylaxis with norfloxacin or trimethoprim-sulfamethoxazole may be considered for patients with prior SBP, low protein ascites, or advanced liver disease 1.

From the Research

Diagnosis and Treatment of Spontaneous Bacterial Peritonitis

• Spontaneous bacterial peritonitis (SBP) is an infection of the ascitic fluid in patients with advanced liver disease and ascites 3.
• The diagnosis of SBP is typically made by analyzing the ascitic fluid for polymorphonuclear leukocyte count, with a count of >250/mm^3 indicating SBP 4.
• The treatment of SBP typically involves the use of broad-spectrum antibiotics, with cefotaxime being the most commonly recommended antibiotic 3, 5, 6.
• Cefotaxime is usually administered at a dose of 2 g every 8 hours for a total of 5 days 3.
• Other antibiotics, such as ceftriaxone and ciprofloxacin, may also be effective in treating SBP, especially in cases where cefotaxime is not effective or in patients with antibiotic resistance 7, 6.

Prevention of Spontaneous Bacterial Peritonitis

• Patients with low-protein ascites (<1g/dL) may benefit from selective intestinal decontamination (SID) with norfloxacin to prevent SBP 3.
• Norfloxacin may also be used to prevent SBP in patients with cirrhosis and upper gastrointestinal bleeding, as well as in patients awaiting liver transplantation 3, 7.
• Long-term antibiotic prophylaxis with norfloxacin may be necessary in patients with a history of SBP or in those with high-risk factors for developing SBP 7.

Complications and Mortality of Spontaneous Bacterial Peritonitis

• SBP is associated with a high mortality rate, ranging from 10% to 30% 3, 5, 7.
• Renal failure, particularly hepatorenal syndrome, is a common complication of SBP and is associated with a high mortality rate 7.
• Infusion of albumin may help reduce the incidence of hepatorenal syndrome and improve survival in patients with SBP 7.