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Spontaneous bacterial peritonitis

Background

Overview

Definition
SBP is a bacterial infection in the peritoneal fluid without any other identifiable source of infection.
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Pathophysiology
SBP is a severe complication of cirrhosis, primarily occurring due to bacterial translocation from the gut to the peritoneal cavity.
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Epidemiology
The incidence of SBP in the US is estimated at 4000 per 100,000 person-years.
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Disease course
Clinical manifestations often include rapid onset of symptoms, including abdominal pain, fever, and altered mental status. Diagnosis is typically made by analyzing ascitic fluid, with a neutrophil count of > 250/mm³ indicating SBP. If not promptly treated, SBP can lead to serious complications such as renal failure, septic shock, and hepatic encephalopathy.
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Prognosis and risk of recurrence
The prognosis of SBP is generally poor, with high in-hospital mortality rates. Factors such as renal dysfunction, high bilirubin levels, and low sodium levels have been associated with increased mortality.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of spontaneous bacterial peritonitis are prepared by our editorial team based on guidelines from the International Collaboration for Transfusion Medicine Guidelines (ICTMG 2024), the American Gastroenterological Association (AGA 2023), the Society of Critical Care Medicine (SCCM 2023), the American Association for the Study of Liver Diseases (AASLD 2021), the British Association ...
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Screening and diagnosis

Diagnostic criteria: as per AASLD 2021 guidelines, establish the diagnosis of SBP with a fluid polymorphonuclear leukocyte count > 250/mm³.
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Diagnostic investigations

Blood culture: as per EASL 2018 guidelines, obtain blood cultures in all patients with suspected SBP before antibiotic treatment initiation.
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  • Abdominal CT

Diagnostic procedures

Diagnostic paracentesis: as per AASLD 2021 guidelines, perform diagnostic abdominal paracentesis to rule out SBP in patients with ascites due to cirrhosis emergently admitted to the hospital, even in the absence of symptoms/signs of infection.
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Medical management

Antibiotic therapy: as per AASLD 2021 guidelines, initiate empiric IV antibiotics in all patients with an ascites/pleural fluid polymorphonuclear count > 250/mm³.
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  • Intravenous albumin

  • Vasoactive agents

  • Medications to avoid

Surgical interventions

Liver transplantation: as per EASL 2018 guidelines, consider performing liver transplantation in patients recovered from SBP, given the poor long-term survival.
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Specific circumstances

Pediatric patients
As per AASLD 2021 guidelines:
Perform diagnostic paracentesis in pediatric patients with ascites and fever, abdominal pain or clinical deterioration. Insufficient evidence to recommend diagnostic paracentesis in all pediatric patients with new ascites but without these symptoms.
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Initiate broad-spectrum antibiotics against both gram-positive and gram-negative organisms in pediatric patients with proven and suspected SBP.
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  • Patients with bacterascites

  • Patients with acute-on-chronic liver failure

Preventative measures

Primary prevention, gastrointestinal hemorrhage: as per AASLD 2021 guidelines, administer antibiotic prophylaxis for SBP in patients with cirrhosis and upper gastrointestinal hemorrhage. Administer IV ceftriaxone 1 g/24 hours as the antibiotic of choice for a maximum of 7 days.
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  • Primary prevention (advanced liver disease)

  • Secondary prevention

Follow-up and surveillance

Assessment of treatment response: as per AASLD 2021 guidelines, consider assessing the response to empirical antibiotic therapy by repeating diagnostic paracentesis 2 days after treatment initiation. Broaden antibiotic coverage and obtain a further evaluation to rule out secondary bacterial peritonitis if a decrease in fluid polymorphonuclear is < 25% from baseline indicating a lack of response.
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