Spontaneous bacterial peritonitis (SBP) is 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 gastrointestinal 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.
Treatment is directed primarily at early administration of appropriate empirical antibiotic regimens. The practitioner must be aware of local resistance patterns, with particular reference to 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 empiric coverage.
Albumin is indicated in the treatment of patients with SBP; particularly for those 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.
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
- abdominal pain or tenderness
- signs of ascites
- altered mental status
- gastrointestinal bleed
Other diagnostic factors
- decompensated hepatic state (usually cirrhosis)
- low ascitic protein/complement
- gastrointestinal bleeding
- endoscopic sclerotherapy for esophageal varices
- ascites due to malignancy, renal insufficiency, or congestive heart failure
- extraintestinal infection
- invasive procedures
1st investigations to order
- serum creatinine
- ascitic fluid appearance
- ascitic fluid absolute neutrophil count (ANC)
- ascitic fluid culture
- blood cultures
- prothrombin time/INR
Investigations to consider
- highly-sensitive leukocyte esterase reagent strip testing of ascitic fluid (Periscreen)
- bedside (standard urine) leukocyte esterase reagent strip testing of ascitic fluid
- ascitic fluid protein, glucose, lactate dehydrogenase (LDH)
- serum-ascites albumin gradient (SAAG)
- ascitic fluid pH and arterial blood pH
- ascitic fluid carcinoembryonic antigen (CEA)
- ascitic fluid alkaline phosphatase
- CT scan abdomen
- ascitic fluid lactoferrin
- ascitic fluid PCR for bacterial DNA
- serum procalcitonin
nosocomial infection, septic shock, high risk for resistant species
Brian Chinnock, MD
Associate Professor of Emergency Medicine
UCSF Fresno Medical Education Program
BC is an author of references cited in this topic.
Andrea De Gottardi, MD, PhD
Hepatic Hemodynamic Laboratory
ADG declares that he has no competing interests.
Kia Saeian, MD
Associate Professor of Medicine
Gastroenterology Fellowship Program
Medical College of Wisconsin
KS declares that he has no competing interests.
Joseph K. Lim, MD
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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- Tuberculous peritonitis
- Intraperitoneal hemorrhage into ascitic fluid
- Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome
- EASL clinical practice guidelines for the management of patients with decompensated cirrhosis
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