Spontaneous Bacterial Peritonitis — SBP

  • CC: Cirrhosis with abdominal pain, fever, AMS, or AKI

  • PP: Ascites, diffuse abdominal pain, fever, chills, worsening encephalopathy, hypotension

  • PN: No clear secondary peritonitis/perforation symptoms unless present

  • pertinent SHx: Alcohol use, liver disease history

  • Etiology: Infection of ascitic fluid without surgically treatable intra-abdominal source

  • risk factors: Cirrhosis, ascites, prior SBP, GI bleed, low ascitic protein, advanced liver disease

  • initial DATA: CBC, CMP, INR, blood cultures, diagnostic paracentesis before antibiotics if possible

  • pending DATA: Ascitic fluid cell count/diff, culture, albumin, total protein, gram stain

  • prior data: Prior SBP/prophylaxis, prior ascites studies

  • MEDS: Diuretics, beta-blockers, lactulose/rifaximin, antibiotics, anticoagulation

  • COURSE:

Plan:

  • Diagnostic paracentesis for all hospitalized cirrhotics with ascites if concern or new admission

  • SBP diagnosis: ascitic PMN ≥250

  • Antibiotics:

    • Ceftriaxone 2 g IV daily

    • Severe/nosocomial/MDR risk: Piperacillin-tazobactam or Meropenem ± Vancomycin depending risk

  • Albumin:

    • 1.5 g/kg day 1

    • 1 g/kg day 3

    • Especially if Cr >1, BUN >30, or bilirubin >4

  • Hold diuretics if AKI/hypotension

  • Blood cultures and ascitic cultures

  • Repeat paracentesis in ~48h if not improving or nosocomial/MDR concern

  • Evaluate for secondary peritonitis if very high PMNs, polymicrobial culture, low glucose, high LDH, poor response

  • GI/hepatology consult if decompensated cirrhosis

  • Duration: usually 5 days if improving

  • Secondary prophylaxis after treatment: usually ciprofloxacin/TMP-SMX per local practice