sbp

Spontaneous bacterial peritonitis (SBP) is an infection of ascitic fluid in the setting of portal hypertension. SBP has a high mortality rate, and patients who develop SBP should be considered for liver transplantation. SBP can present with fever, abdominal pain, and kidney disease, but its presence should be considered in any patient with ascites who experiences a decline in condition. Patients with very low total protein levels in their ascitic fluid (<1.5 g/dL [15 g/L]) in conjunction with serum sodium level less than or equal to 130 mEq/L (130 mmol/L), serum creatinine level greater than or equal to 1.2 mg/dL (106.1 µmol/L), blood urea nitrogen level greater than or equal to 25 mg/dL (8.9 mmol/L), serum bilirubin level greater than or equal to 3 mg/dL (51.3 µmol/L), or Child-Turcotte-Pugh class B or C cirrhosis are at high risk for development of SBP and should be given long-term primary prophylaxis with a fluoroquinolone antibiotic (for example, norfloxacin or ciprofloxacin).

The diagnosis of SBP is established by an ascitic-fluid neutrophil count of 250/µL or higher on diagnostic paracentesis. Bacterial culture of ascitic fluid should also be obtained. Prompt initiation of therapy with a third-generation cephalosporin (for example, cefotaxime) is the initial treatment of SBP. If patients have kidney dysfunction, or significant hepatic dysfunction as measured by a serum bilirubin level greater than 4 mg/dL (68 µmol/L), adjunctive therapy with albumin (1.5 g/kg body weight on day 1, as well as 1 g/kg on day 3) should be administered; such treatment has a demonstrated survival benefit.

Follow-up paracentesis to demonstrate improvement in inflammation can be performed if clinical improvement is not obvious. Indefinite secondary prophylactic therapy should be offered to patients after resolution of SBP and typically consists of once-daily fluoroquinolone therapy.

Prophylaxis

Criterias

Abx

Treatment

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