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.
Empiric 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 likely require broader initial empiric 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 <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.
History and exam
- 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
- prothrombin time/INR
- ascitic fluid pH and arterial blood pH
Associate Professor of Emergency Medicine
UCSF Fresno Medical Education Program
BC is an author of a number of references cited in this monograph.
Hepatic Hemodynamic Laboratory
ADG declares that he has no competing interests.
Associate Professor of Medicine
Gastroenterology Fellowship Program
Medical College of Wisconsin
KS declares that he has no competing interests.
Assistant Professor of Medicine
Yale Viral Hepatitis Program
Section of Digestive Diseases
Yale School of Medicine
JKL declares that he has no competing interests.
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