What is the management approach for a patient with a history of cirrhosis suspected of having Spontaneous Bacterial Peritonitis (SBP)?

Management of Spontaneous Bacterial Peritonitis in Cirrhosis

Immediately perform diagnostic paracentesis on any cirrhotic patient with ascites at hospital admission—even without symptoms—and start empirical cefotaxime 2g IV every 8 hours plus albumin 1.5 g/kg within 6 hours if the ascitic fluid neutrophil count exceeds 250/mm³. 1, 2, 3

Diagnostic Approach

When to Perform Paracentesis

Perform diagnostic paracentesis urgently in the following scenarios:

• All hospitalized cirrhotic patients with ascites at admission, regardless of symptoms, as 16% of SBP cases are completely asymptomatic 1, 3
• Fever, hypothermia, or signs of systemic inflammation 1
• Abdominal pain, tenderness, vomiting, diarrhea, or ileus 1, 2
• Worsening hepatic encephalopathy or altered mental status 1, 4
• Acute kidney injury or worsening renal function 1
• Gastrointestinal bleeding 1, 3
• Shock or hemodynamic instability 1
• Deteriorating liver function 1

Diagnostic Criteria

• SBP is diagnosed when ascitic fluid polymorphonuclear (PMN) count >250/mm³, regardless of culture results 1, 2, 3
• Inoculate at least 10 mL of ascitic fluid into blood culture bottles at bedside before antibiotics to increase culture sensitivity to >90% 1, 3
• Obtain simultaneous blood cultures before starting antibiotics 1, 3
• Do not wait for culture results to initiate treatment—the PMN count alone is sufficient 1, 3

Critical Pitfall: Secondary Bacterial Peritonitis

Suspect secondary (surgical) peritonitis if:

• Multiple organisms on culture 1, 5
• Localized abdominal symptoms with peritoneal signs 1, 5
• Very high ascitic neutrophil count (often >1,000/mm³) 5
• Inadequate response to appropriate antibiotics after 48 hours 1, 2
• High ascitic protein concentration 1

Obtain urgent CT imaging and surgical consultation if secondary peritonitis is suspected 1, 2, 3

Immediate Treatment Protocol

First-Line Antibiotic Therapy

• Cefotaxime 2g IV every 8 hours for 5 days is the gold standard with 77-98% resolution rates 2, 3
• Alternative: Cefotaxime 2g IV every 6 hours for more severe presentations 2, 3
• A 5-day course is as effective as 10 days 2, 3
• For uncomplicated community-acquired SBP in non-critically ill patients: oral ofloxacin 400mg twice daily 3

Albumin Administration (Critical for Mortality Reduction)

• 1.5 g/kg body weight IV within 6 hours of diagnosis 2, 3, 6
• 1.0 g/kg IV on day 3 2, 3, 6
• This regimen reduces mortality from 29% to 10% and decreases hepatorenal syndrome from 30% to 10% 3

Special Populations Requiring Broader Coverage

Do NOT use third-generation cephalosporins alone in:

• Nosocomial SBP (acquired >48 hours after admission)—consider piperacillin-tazobactam or carbapenem 4, 7, 8
• Patients already on quinolone prophylaxis—use cefotaxime or amoxicillin-clavulanic acid 3
• Healthcare-associated infections (contact with healthcare facility <90 days)—consider broader spectrum 7, 8
• Areas with high quinolone resistance 3
• Septic shock or failure to improve on standard therapy—consider adding antifungal coverage for possible spontaneous fungal peritonitis 7

Monitoring Treatment Response

48-Hour Reassessment

• Perform repeat paracentesis at 48 hours to assess treatment efficacy 2, 3
• Treatment success: PMN count decreases to <25% of pre-treatment value with clinical improvement 2, 3
• Treatment failure: PMN count fails to decrease by at least 25% or worsening clinical signs 2, 3

Management of Treatment Failure

If treatment fails at 48 hours:

• Broaden antibiotic coverage based on culture sensitivities or empirically escalate to carbapenem/piperacillin-tazobactam 2, 3, 8
• Obtain CT imaging to exclude secondary bacterial peritonitis requiring surgical intervention 1, 2, 3
• Consider spontaneous fungal peritonitis, especially in nosocomial cases with septic shock 7

Special Clinical Scenarios

Culture-Negative Neutrocytic Ascites

• Treat identically to culture-positive SBP if PMN >250/mm³ with negative culture 3, 5
• Both have similar morbidity and mortality 3

Bacterascites (Positive Culture, PMN <250/mm³)

• If symptomatic with signs of infection: treat as SBP 1, 3
• If asymptomatic: repeat paracentesis, as 38% will progress to frank SBP 3
• If repeat culture remains positive regardless of PMN count: initiate treatment 1

Prognostic Considerations

• SBP carries approximately 20% hospital mortality despite infection resolution 2, 3
• Each hour delay in antibiotic initiation increases mortality by 10% in cirrhotic patients with septic shock 1, 3, 5
• Early appropriate antibiotic treatment combined with albumin therapy significantly improves survival 2, 3
• Community-acquired SBP has better prognosis than nosocomial SBP 9
• Acute-on-chronic liver failure (ACLF) with SBP has 89% mortality 10

Key Pitfalls to Avoid

• Never delay antibiotics waiting for culture results—mortality increases 10% per hour in septic shock 1, 3, 5
• Never omit albumin therapy—it reduces mortality by two-thirds 3
• Never use quinolones in patients already on quinolone prophylaxis 3
• Never assume third-generation cephalosporins are adequate for nosocomial SBP—multidrug-resistant organisms are increasingly common 4, 7, 8, 10
• Never miss secondary bacterial peritonitis—it requires surgical intervention, not just antibiotics 1, 2, 3, 5

budget:budget_used 8753 7990 763 0.04