Spontaneous bacterial peritonitis

Last reviewed: April 2019

Last updated: March 2018

Summary

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.

Definition

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.

History and exam

Key diagnostic factors

presence of risk factors
abdominal pain or tenderness
signs of ascites
fever
nausea/vomiting
diarrhoea
altered mental status
GI bleed

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Other diagnostic factors

hypothermia
hypotension
tachycardia

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Risk factors

decompensated hepatic state (usually cirrhosis)
low ascitic protein/complement
GI bleeding
sclerosis of oesophageal varices
malignant ascites
extraintestinal infection
invasive procedures

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Diagnostic investigations

1st investigations to order

FBC
serum creatinine
ascitic fluid appearance
ascitic fluid absolute neutrophil count (ANC)
ascitic fluid Gram stain
ascitic fluid culture
highly-sensitive leukocyte esterase reagent strip testing of ascitic fluid (Periscreen)
bedside (standard urine) leukocyte esterase reagent strip testing of ascitic fluid
blood cultures
LFT
PT/INR
ascitic fluid pH and arterial blood pH

Full details

Investigations to consider

ascitic fluid protein, glucose, lactate dehydrogenase (LDH)
ascitic fluid carcinoembryonic antigen (CEA)
ascitic fluid alkaline phosphatase
CT scan abdomen

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Emerging tests

ascitic fluid lactoferrin
ascitic fluid granulocyte elastase (latex immunoassay test)
ascitic fluid PCR for bacterial DNA
short corticotrophin stimulation test
serum procalcitonin

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Treatment algorithm

ACUTE

Contributors

Authors VIEW ALL 

Brian Chinnock, MD

Associate Professor of Emergency Medicine

UCSF Fresno Medical Education Program

Fresno

Disclosures

BC is an author of a number of references cited in this monograph.

Peer reviewers VIEW ALL 

Andrea De Gottardi, MD, PhD

Visiting Hepatologist

Hepatic Hemodynamic Laboratory

Liver Unit

Hospital Clinic

Barcelona

Spain

Disclosures

ADG declares that he has no competing interests.

Kia Saeian, MD

Associate Professor of Medicine

Program Director

Gastroenterology Fellowship Program

Medical College of Wisconsin

Milwaukee

Disclosures

KS declares that he has no competing interests.

Joseph K. Lim, MD

Assistant Professor of Medicine

Director

Yale Viral Hepatitis Program

Section of Digestive Diseases

Yale School of Medicine

New Haven

Disclosures

JKL declares that he has no competing interests.

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Spontaneous bacterial peritonitis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Emerging tests

Treatment algorithm

sepsis, encephalopathy, or GI bleeding

without sepsis, encephalopathy, or GI bleeding

primary or secondary prevention

Contributors

Authors VIEW ALL 

Brian Chinnock, MD

Disclosures

Peer reviewers VIEW ALL 

Andrea De Gottardi, MD, PhD

Disclosures

Kia Saeian, MD

Disclosures

Joseph K. Lim, MD

Disclosures

Differentials

Guidelines

Procedural videos

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