Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 15-09: Spontaneous Bacterial Peritonitis + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ A history of chronic liver disease and ascites Fever and abdominal pain Peritoneal signs uncommonly encountered on examination Ascitic fluid neutrophil count > 250 white blood cells (WBC)/mcL +++ General Considerations ++ Occurs with few exceptions in patients with ascites caused by chronic liver disease Affects ~20–30% of cirrhotic patients Most common pathogens are enteric gram-negative bacteria (Escherichia coli, Klebsiella pneumoniae) or gram-positive bacteria (Streptococcus pneumoniae, viridans streptococci, Enterococcus) Patients with ascitic fluid total protein of < 1 g/dL are at increased risk + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Symptoms in 80–90%; asymptomatic in 10–20% Fever and abdominal pain present in two-thirds Change in mental status due to precipitation or exacerbation of hepatic encephalopathy Signs of chronic liver disease with ascites Abdominal tenderness in < 50% +++ Differential Diagnosis ++ Secondary bacterial peritonitis, eg, appendicitis, diverticulitis, perforated peptic ulcer, perforated gallbladder Peritoneal carcinomatosis Pancreatic ascites Tuberculous ascites + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Kidney dysfunction, abrupt worsening of kidney function Ascitic fluid polymorphonuclear neutrophil (PMN) count of > 250 cells/mcL (neutrocytic ascites) or percentage of PMNs > 50–70% of the ascitic fluid WBC count is presumptive evidence of bacterial peritonitis Ascitic fluid Gram stain and reagent strips are insensitive Ascitic fluid cultures should be obtained by inoculating blood culture bottles at the bedside 10–30% of patients with neutrocytic ascites have negative ascitic bacterial cultures ("culture-negative neutrocytic ascites"), but are presumed nonetheless to have bacterial peritonitis and treated empirically Blood cultures occasionally are positive, which helps identify the organism when ascitic fluid cultures are negative +++ Imaging Studies ++ Abdominal CT imaging should be obtained to look for evidence of an intra-abdominal source of infection +++ Diagnostic Procedures ++ Abdominal paracentesis + Treatment Download Section PDF Listen +++ +++ Medications ++ Empiric therapy should be initiated with a third-generation cephalosporin Cefotaxime, 2 g intravenously every 8–12 hours Ceftriaxone, 1–2 g intravenously every 24 hours Combination β-lactam/β-lactamase agent, such as ampicillin/sulbactam 2 g/1 g intravenously every 6 hours Aminoglycosides Recommended duration of antibiotic is 5–10 days or until the ascites fluid PMN count decreases to < 250 cells/mcL If the ascitic neutrophil count has not decreased by 25%, antibiotic coverage should be adjusted (guided by culture and sensitivity results, if available) and secondary causes of peritonitis excluded If the ascitic PMN count has decreased but remains more than 250 cells/mcL, antibiotics should be continued for an additional 2–3 days before paracentesis is repeated Should not be used in patients with chronic liver disease because of a high risk of nephrotoxicity Intravenous albumin, 1.5 g/kg on day 1 and 1 g/kg on day 3, should be administered to patients at high risk for hepatorenal failure (ie, those with baseline creatinine > 1.0 mg/dL, BUN > 30 mg/dL, or bilirubin > 4 mg/dL) Nonselective β-blockers Increase the risk of hepatorenal syndrome in cirrhotic patients with spontaneous bacterial peritonitis Should be discontinued permanently due to adverse impact on cardiac output and renal perfusion in advanced cirrhosis Patients with suspected secondary bacterial peritonitis should be given broad-spectrum coverage for enteric aerobic and anaerobic flora with a third-generation cephalosporin and metronidazole +++ Surgery ++ Liver transplant is the most effective treatment for recurrent spontaneous bacterial peritonitis + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ Patients without significant clinical improvement after taking an aminoglycoside for 5 days should undergo repeat paracentesis to assess treatment efficacy +++ Complications ++ Acute kidney failure develops in up to 40% of patients and is a major cause of death +++ Prognosis ++ Mortality rate is 25%, but if recognized and treated early, mortality is < 10% Causes of death include liver failure, hepatorenal syndrome, or bleeding complications +++ Prevention ++ Up to 70% of patients who survive an episode of spontaneous bacterial peritonitis will have another episode within 1 year Oral once-daily prophylactic therapy has been shown to reduce the rate of recurrent infections to < 20% and is recommended Ciprofloxacin, 500 mg orally once daily Trimethoprim-sulfamethoxazole, one double-strength tablet orally once daily Norfloxacin, 400 mg orally once daily (no longer available in the United States) Primary prophylaxis is recommended in patients with no history of spontaneous bacterial peritonitis but who are at increased risk for infection due to low-protein ascites (total ascitic fluid protein < 1.5 g/dL) with impaired kidney function (serum creatinine ≥ 1.2 g/dL) or decompensated cirrhosis (Child-Pugh class C) Prophylactic antibiotics are associated with a lower risk spontaneous bacterial peritonitis, hepatorenal syndrome, and mortality +++ When to Refer ++ Patients failing to improve within 3–5 days of initial therapy Patients with possible secondary peritonitis, ie, ascites infected by an intra-abdominal infection (appendicitis, diverticulitis) Consider secondary peritonitis in patients with Ascites total protein < 1 g/dL, glucose < 50 mg/dL, or ascites lactate dehydrogenase (LD) > upper limit of normal for serum LD Polymicrobial infection High ascitic neutrophil counts (> 10,000/mcL) +++ When to Admit ++ Symptomatic patients require admission for intravenous antibiotics Selected asymptomatic patients may be treated with oral antibiotics with close follow-up + References Download Section PDF Listen +++ + +Fiore M et al. Are third-generation cephalosporins still the empirical antibiotic treatment of community-acquired spontaneous bacterial peritonitis? A systematic review and meta-analysis. Eur J Gastroenterol Hepatol. 2018 Mar;30(3):329–36. [PubMed: 29303883] + +Bajaj JS et al. Outcomes in patients with cirrhosis on primary compared to secondary prophylaxis for spontaneous bacterial peritonitis. Am J Gastroenterol. 2019 Apr;114(4):599–606. [PubMed: 30694868] + +Gaetano JN et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. J Gastroenterol Hepatol. 2016 May;31(5):1025–30. [PubMed: 26642977] + +Garcia-Tsao G. Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Dig Dis. 2016;34(4):382–6. [PubMed: 27170392] + +Iogna Prat L et al. Antibiotic treatment for spontaneous bacterial peritonitis in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev. 2019 Sep 16;9:CD013120. [PubMed: 31524949] + +Jamtgaard L et al. Does albumin infusion reduce renal impairment and mortality in patients with spontaneous bacterial peritonitis? Ann Emerg Med. 2016 Apr;67(4):458–9. [PubMed: 26234193] + +Pericleous M et al. The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and recommendations. Eur J Gastroenterol Hepatol. 2016 Mar;28(3):e10–8. [PubMed: 26671516] + +Sidhu GS et al. Rifaximin versus norfloxacin for prevention of spontaneous bacterial peritonitis: a systematic review. BMJ Open Gastroenterol. 2017 Jul 17;4(1):e000154. [PubMed: 28944070]