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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 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
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
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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