Is Spontaneous Bacterial Peritonitis Surgical?
No, spontaneous bacterial peritonitis (SBP) is NOT a surgical condition and is treated with antibiotics alone. 1
Key Distinction: SBP vs. Secondary Peritonitis
SBP is Medical, Not Surgical
- SBP is defined as bacterial infection of ascitic fluid WITHOUT any intra-abdominal surgically treatable source of infection 2
- Treatment consists of immediate empiric antibiotics (third-generation cephalosporin such as cefotaxime 2g IV every 8 hours) plus albumin infusion 1
- Surgery is contraindicated in true SBP, as unnecessary laparotomy in cirrhotic patients increases mortality 1
- The mortality of SBP treated with antibiotics alone is similar to secondary peritonitis treated with antibiotics plus surgery 1
Secondary Peritonitis DOES Require Surgery
You must distinguish secondary bacterial peritonitis from SBP, as this condition requires surgical intervention 1
Secondary peritonitis should be suspected when:
- Multiple organisms are present on Gram stain or culture (vs. monomicrobial in SBP) 1, 2
- Ascitic PMN count is very high (often >1,000/mm³) 1
- Ascitic total protein ≥1 g/dL 1
- Ascitic LDH exceeds upper limit of normal for serum 1
- Ascitic glucose <50 mg/dL 1
- Ascitic fluid CEA >5 ng/mL or alkaline phosphatase >240 U/L (suggests gut perforation) 1
- PMN count rises despite appropriate antibiotic treatment 1
Management Algorithm for Suspected Peritonitis
When SBP is Confirmed (PMN >250/mm³, typical features):
- Start antibiotics immediately - cefotaxime 2g IV every 8 hours 1
- Administer albumin - 1.5 g/kg within 6 hours, then 1.0 g/kg on day 3 1, 3
- No surgical consultation needed 1
- Infection resolution occurs in 77-98% with antibiotics alone 1
When Secondary Peritonitis is Suspected:
- Obtain urgent CT scanning 1
- Add anaerobic coverage to third-generation cephalosporin 1
- Obtain immediate surgical consultation for laparotomy 1
- These patients have documented gut perforation or intra-abdominal abscess requiring surgical source control 1
Critical Pitfall to Avoid
The most dangerous error is performing unnecessary surgery on a patient with true SBP 1. Approximately 5% of patients initially suspected to have SBP actually have secondary peritonitis requiring surgery 1. However, the vast majority (95%) have true SBP and should receive medical management only.
If the clinical picture is atypical (unusual organisms, inadequate response to antibiotics, localized symptoms), repeat paracentesis at 48 hours can help distinguish secondary peritonitis from SBP 1, 3. In SBP, the PMN count drops dramatically with treatment; in secondary peritonitis, it rises despite treatment 1.