Spontaneous bacterial peritonitis

One of the most frequently encountered bacterial infections in patients with cirrhosis, and most commonly seen in patients with end-stage liver disease.

Key symptoms are abdominal pain, fever, vomiting, altered mental status, and GI bleeding. However, patients are commonly minimally symptomatic, and may even be asymptomatic.

Ascitic fluid laboratory tests should include cell count and culture. Bedside (standard urine) leukocyte esterase reagent strip testing of ascitic fluid has a role in the rapid diagnosis of spontaneous bacterial peritonitis (SBP); highly-sensitive leukocyte esterase reagent strip testing of ascitic fluid may be used to rule out SBP.

Defined by an ascitic fluid absolute neutrophil count >250 cells/mm³, whether or not there is culture growth.

Empirical antibiotic regimens include cefotaxime, ceftriaxone, fluoroquinolones, and ampicillin/sulbactam. However, caution must be used in antibiotic choice as changing resistance patterns have been demonstrated, including increased third-generation cephalosporin and fluoroquinolone resistance.

Patients with sepsis, history of fluoroquinolone prophylaxis, nosocomial-acquired SBP, or a history of previous infections with resistant organisms are likely to require broader initial empirical coverage.

Albumin is indicated in the treatment of patients with renal dysfunction.

Continuous antibiotic prophylaxis is indicated in patients with an ascitic fluid protein concentration <15 g/L (<1.5 g/dL) or a previous episode of SBP. Ciprofloxacin, trimethoprim/sulfamethoxazole, or rifaximin may be effective for primary and secondary prevention of SBP.

Spontaneous bacterial peritonitis (SBP) is an infection of ascitic fluid that cannot be attributed to any intra-abdominal, ongoing inflammatory, or surgically correctable condition. It is one of the most frequently encountered bacterial infections in patients with cirrhosis.