From the Guidelines
Spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites is diagnosed when the ascitic fluid neutrophil count exceeds 250 cells/mm³, typically confirmed by paracentesis, and treatment should begin immediately with third-generation cephalosporins, such as cefotaxime 2g IV every 8 hours for 5-7 days, as recommended by the most recent guidelines 1.
Diagnosis and Treatment
The diagnosis of SBP is based on the ascitic fluid neutrophil count, which is determined by microscopy or automated count, and ascitic fluid culture should be performed to guide antibiotic therapy 1.
- Diagnostic paracentesis should be carried out in all patients with cirrhosis and ascites at hospital admission to rule out SBP, and in patients with gastrointestinal bleeding, shock, fever, or other signs of systemic inflammation, gastrointestinal symptoms, as well as in patients with worsening liver and/or renal function, and hepatic encephalopathy 1.
- The treatment of SBP should include albumin infusion (1.5g/kg on day 1, followed by 1g/kg on day 3) alongside antibiotics to reduce the risk of renal impairment and improve survival 1.
- After successful treatment, all patients should receive long-term prophylaxis with norfloxacin 400mg daily or trimethoprim-sulfamethoxazole to prevent recurrence 1.
Prophylaxis
Prophylactic antibiotic treatment should be considered in patients with cirrhosis and ascites who are at high risk of developing SBP, such as those with a history of SBP, gastrointestinal bleeding, or low ascitic fluid protein levels 1.
- Norfloxacin and trimethoprim-sulfamethoxazole are commonly used for prophylaxis, and the choice of antibiotic should be guided by local resistance patterns and patient-specific factors 1.
Monitoring and Follow-up
Patients with SBP should be monitored closely for signs of resolution, including improvement in clinical symptoms and reduction in ascitic fluid neutrophil count on repeat paracentesis 1.
- A second diagnostic paracentesis at 48 hours from the start of treatment may be considered to check the efficacy of antibiotic therapy and to rule out secondary bacterial peritonitis 1.
From the Research
Diagnosis of Spontaneous Bacterial Peritonitis (SBP)
- SBP is a common complication in patients with liver cirrhosis, with an increased risk of mortality 2
- Diagnostic paracentesis should be performed in all patients with ascites and clinical features with high diagnostic suspicion 2, 3
- The final diagnosis requires the analysis of ascites and the presence of > 250 mm3 neutrophil polymorphonuclear (PMN) in ascites 2
- Ascitic fluid should be placed in blood culture bottles to improve the culture yield 3
- Leukocyte esterase reagent strips can be used for rapid diagnosis if available 3
Treatment of Spontaneous Bacterial Peritonitis (SBP)
- Prompt and effective treatment is required to prevent outcomes, but this becomes challenging as first-line therapies may become ineffective leading to worsening prognosis and increased in-hospital mortality 2
- Management traditionally includes a third-generation cephalosporin, but specific patient populations may require more broad-spectrum coverage with a carbapenem or piperacillin-tazobactam 3
- Albumin infusion is associated with reduced risk of renal impairment and mortality 3, 4
- The treatment of choice is cefotaxime 2 g given intravenously every 8 hours for a total of 5 days, but the antibiotic regimen is adjusted based on the results of ascitic fluid cultures 4
Risk Factors and Prevention of Spontaneous Bacterial Peritonitis (SBP)
- Gram-positive cocci (GPC) such as Staphylococcus, Enterococcus as well as multi-resistant bacteria have become common pathogens and have changed the conventional approach to treatment of SBP 5
- Health care-associated and nosocomial SBP infections should prompt greater vigilance and consideration for alternative antibiotic coverage 5
- Acid suppressive and beta-adrenergic antagonist therapies are strongly associated with SBP in at-risk individuals 5
- Selective intestinal decontamination (SID) with the oral fluoroquinolone norfloxacin is an effective form of prophylaxis 4
- Liver transplant evaluation should be undertaken for patients who develop SBP barring contraindications 5