From the Guidelines
Spontaneous bacterial peritonitis (SBP) is a serious infection that requires prompt treatment with antibiotics, typically a third-generation cephalosporin like cefotaxime, as recommended by the most recent guidelines 1. The diagnosis of SBP is made by performing a diagnostic paracentesis, which should be carried out without delay in all cirrhotic patients with ascites on hospital admission, and the ascitic neutrophil count should be >250/mm3 to confirm the diagnosis 1. Some key points to consider in the diagnosis and treatment of SBP include:
- Diagnostic paracentesis should be performed in patients with GI bleeding, shock, fever or other signs of systemic inflammation, gastrointestinal symptoms, hepatic encephalopathy, and in patients with worsening liver or renal function 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 context of SBP (community acquired or health-care associated), severity of infection and local bacterial resistance profile 1.
- A second diagnostic paracentesis at 48 hours from the start of treatment to check the efficacy of antibiotic therapy should be considered in those who have apparently inadequate response or where secondary bacterial peritonitis is suspected 1.
- Patients presenting with gastrointestinal bleeding and underlying ascites due to cirrhosis should receive prophylactic antibiotic treatment to prevent the development of SBP 1.
- Patients who have recovered from an episode of SBP should be considered for treatment with norfloxacin, ciprofloxacin, or co-trimoxazole to prevent further episode of SBP 1. The choice of antibiotic should be guided by local resistance patterns, and the treatment duration should vary according to the symptoms and/or results of antimicrobial susceptibility testing 1. In patients with SBP and signs of developing renal impairment, albumin should be given at 1.5 g albumin/kg in the first six hours followed by 1 g/kg on day 3 1. It is crucial to separate community-acquired SBP from health care-associated and nosocomial SBP and to consider both the severity of infection and the local resistance profile in order to decide the empirical antibiotic treatment of SBP 1. Overall, the management of SBP requires a comprehensive approach that includes prompt diagnosis, appropriate antibiotic treatment, and consideration of the underlying liver disease and potential complications.