From the Guidelines
To calculate spontaneous bacterial peritonitis (SBP) in ascites, obtain a sample of ascitic fluid through paracentesis and send it for cell count with differential, where SBP is diagnosed when the neutrophil count in the ascitic fluid is ≥250 cells/mm³ without evidence of an intra-abdominal surgically treatable source of infection, as recommended by the most recent guidelines 1. The diagnosis of SBP is crucial in patients with cirrhosis and ascites, as it is a serious complication with high mortality.
- The ascitic fluid should be cultured at the bedside in aerobic and anaerobic blood culture bottles before initiation of antibiotics, as suggested by 1.
- Treatment should begin immediately with antibiotics when SBP is diagnosed, with first-line therapy typically being ceftriaxone 1-2g IV daily for 5-7 days, or alternatively, a fluoroquinolone like ciprofloxacin 400mg IV twice daily or levofloxacin 500mg IV daily.
- For patients with SBP, albumin infusion (1.5 g/kg on day 1 and 1 g/kg on day 3) is recommended to reduce the risk of renal impairment and mortality, as supported by the latest evidence 1.
- After treatment, secondary prophylaxis with norfloxacin 400mg daily or trimethoprim-sulfamethoxazole is recommended for patients who have recovered from an episode of SBP. The use of albumin in SBP has been shown to improve outcomes, particularly in patients with AKI and/or jaundice, as demonstrated by recent studies 1.
- It is essential to note that albumin should not be used in patients with cirrhosis and uncomplicated ascites, as stated in 1.
- The diagnosis and treatment of SBP should be prompt, as delayed treatment can lead to increased morbidity and mortality, highlighting the importance of following the latest guidelines 1.
From the Research
Calculation of SBP Ascites
To calculate SBP ascites, we need to consider the following factors:
- Ascitic fluid analysis
- Polymorphonuclear cell count
- Ascites total protein
- Lactate dehydrogenase
- Glucose levels
Key Findings
- The ascitic fluid polymorphonuclear cell count is the most sensitive test in evaluating for infection 2
- Cultures of the ascitic fluid are helpful in identifying the organism and are best performed by bedside injection of blood culture bottles 2
- Ascites total protein, lactate dehydrogenase, and glucose levels can assist in distinguishing SBP from secondary peritonitis 2
Risk Factors
- Advanced age
- Refractory ascites
- Variceal bleeding
- Renal failure
- Low albumin levels (below 2.5 g/ml)
- Bilirubin over 4 mg/dl
- Child-Pugh class C
- Previous diagnosis of SBP 3
Treatment
- Empirical therapy is recommended after paracentesis if suspicion for infection exists 2
- Cefotaxime is the best-studied antibiotic for this purpose and has excellent penetration into ascites with no nephrotoxicity 2
- Third-generation, broad-spectrum cephalosporins remain a good initial choice for SBP treatment 4
- Levofloxacin is an acceptable alternative for patients not receiving long-term flouroquinolone prophylaxis or for those with a penicillin allergy 4
Prevention
- Long-term antibiotic prophylaxis with norfloxacin is indicated for patients with advanced age, refractory ascites, variceal bleeding, renal failure, low albumin levels, bilirubin over 4 mg/dl, Child-Pugh class C, and a previous diagnosis of SBP 3
- Selective albumin supplementation remains an important adjunct in SBP treatment 4