Spontaneous bacterial peritonitisMANAGEMENT

INFECTIOUS DISEASE PRESENTATIONS · 12 SECTIONS

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481 items

☷ Legend

01Approach to the Critical Patient/attcp55

Immediate priorities

›Initial stabilization

›Airway compromise

›Encephalopathy with loss of protective reflexes

›Massive hematemesis with aspiration risk

›Breathing failure

›Hypoxemia

›Increased work of breathing

›Circulation threats

›Hypotension or shock

›Active GI bleeding

›Sepsis pathway

›Lactate trend in mmol/L

›Blood cultures x 2 before antibiotics if no delay

›Early recognition triggers

›Cirrhosis with ascites

›Fever

›Abdominal pain or tenderness

›Non-specific deterioration

›Encephalopathy

›AKI or rising creatinine

›Hemodynamic change

›New hypotension

›New tachycardia

›Time-critical procedure

›Diagnostic paracentesis within 12 hours of presentation

›Perform before antibiotics when feasible

›Do not delay antibiotics in shock

Hemodynamic and monitoring targets

›Monitoring and access

›Continuous monitoring

›Cardiac monitor

›Pulse oximetry

›IV access

›Two large-bore peripheral lines

›Central access if poor peripheral access or vasopressors needed

›Urine output monitoring

›Foley catheter for shock or AKI

›Target urine output 0.5 mL/kg/hour

›Resuscitation targets

›Mean arterial pressure at least 65 mmHg in septic shock

›Norepinephrine first-line vasopressor

›Albumin favored over large-volume crystalloid for cirrhosis-related circulatory dysfunction

Consult and escalation triggers

›Early specialty involvement

›Hepatology or gastroenterology

›Confirm prophylaxis plan

›Evaluate for transplant pathway when appropriate

›ICU

›Vasopressor requirement

›Rising lactate despite resuscitation

›Source control pathway

›If concern for secondary peritonitis, urgent surgery consult

›Peritoneal signs

›Polymicrobial Gram stain or culture

›If biliary or intra-abdominal source on imaging, urgent interventional radiology consult

›Drainable collection

›Cholecystitis or cholangitis

02History/hx48

Presenting features and risk profile

›Symptom pattern

›Infectious symptoms

›Fever or chills

›Malaise

›Abdominal symptoms

›Pain

›Increasing distension

›Neurocognitive symptoms

›Confusion

›Somnolence

›Cirrhosis context

›Ascites history

›Prior paracentesis frequency

›Prior SBP episodes

›Decompensation markers

›Variceal bleeding history

›Encephalopathy history

›Medication and exposure risks

›Antibiotic exposures in past 90 days

›Resistant organism risk

›C difficile risk

›Proton pump inhibitor use

›SBP risk association

›Deprescribing opportunity if no clear indication

›Prophylaxis status

›Current SBP prophylaxis

›Norfloxacin or ciprofloxacin

›TMP-SMX

›Adherence and recent interruptions

›Missed doses

›Access barriers

Red flags for alternate diagnosis

›Secondary peritonitis clues

›Severe focal abdominal pain

›Localized tenderness

›Rebound or guarding

›Recent abdominal surgery or instrumentation

›Peritoneal dialysis

›Recent endoscopy with perforation risk

›Bowel ischemia risk

›Atrial fibrillation

›Severe hypotension episode

›Spontaneous fungal peritonitis risk

›Broad-spectrum antibiotic exposure

›Prolonged courses

›Recent ICU admission

›High MELD or severe immunocompromise

›Steroid therapy

›Malignancy chemotherapy

03Physical Exam/exam39

Key findings and severity cues

›General appearance

›Toxic appearance

›Rigors

›Altered mental status

›Volume status

›Dry mucous membranes

›Peripheral edema

›Vital signs pattern

›Infection physiology

›Fever

›Tachycardia

›Shock physiology

›Hypotension

›Cool extremities

›Abdominal exam

›Ascites

›Shifting dullness

›Fluid wave

›Peritoneal irritation

›Rebound tenderness

›Guarding

›Cirrhosis stigmata and complications

›Encephalopathy signs

›Asterixis

›Disorientation

›GI bleeding signs

›Melena

›Hematemesis

PITFALLS

›Misleading normal exam

›Minimal abdominal tenderness despite SBP

›Blunted inflammatory response

›Analgesic masking

›Afebrile SBP

›Advanced cirrhosis immuneparesis

›Antipyretic use

›Procedure safety assumptions

›Coagulopathy not a contraindication to diagnostic paracentesis in most cases

›Low bleeding complication rates with ultrasound guidance

›Platelet transfusion typically not required for routine diagnostic taps

04Differential Diagnosis/ddx32

Infectious and inflammatory causes

›Primary diagnosis

›Spontaneous bacterial peritonitis (ICD-10 K65.2)

›Monomicrobial infection of ascitic fluid

›PMN threshold driven diagnosis

›Culture-negative neutrocytic ascites

›PMN at least 250 cells/mm3

›Negative culture after appropriate sampling

›Related syndromes

›Monomicrobial non-neutrocytic bacterascites

›Positive culture

›PMN less than 250 cells/mm3

›Spontaneous fungal peritonitis

›Yeast on Gram stain

›Fungal culture positive

›Non-infectious mimics

›Pancreatitis (ICD-10 K85)

›Epigastric pain

›Lipase elevation

›Perforated viscus (ICD-10 K63.1 or K25-K28 with perforation)

›Free air on imaging

›Acute peritonitis

›Mesenteric ischemia (ICD-10 K55.0)

›Pain out of proportion

›Elevated lactate

Secondary peritonitis and surgical abdomen

›Secondary bacterial peritonitis (ICD-10 K65.9)

›Polymicrobial infection

›Multiple organisms on Gram stain or culture

›Failure to improve with standard SBP therapy

›Runyon criteria support

›Ascitic total protein greater than 10 g/L

›Ascitic glucose less than 2.8 mmol/L

›Ascitic LDH greater than serum upper limit of normal

05Laboratory Tests/lt47

Core labs and organ failure staging

›Baseline severity labs

›CBC

›Leukocytosis or leukopenia

›Thrombocytopenia as portal hypertension marker

›CMP

›Creatinine trend for AKI

›Sodium trend for hyponatremia

›Liver panel

›Bilirubin

›AST and ALT

›Coagulation profile

›INR

›Fibrinogen if bleeding concern

›Sepsis and perfusion labs

›Lactate in mmol/L

›Serial trend for resuscitation response

›Persistent elevation as shock marker

›Blood cultures x 2

›Prior to antibiotics if no delay

›Repeat if persistent fever or shock

Ascitic fluid studies

›Diagnostic paracentesis panel

›Cell count with differential

›PMN at least 250 cells/mm3 diagnostic of SBP

›PMN correction for bloody tap

›Culture technique

›Bedside inoculation into aerobic and anaerobic blood culture bottles

›Improved yield versus syringe to lab alone

›Albumin and total protein

›SAAG support for portal hypertension physiology

›Low protein as SBP risk marker

›Additional ascitic tests for alternate etiologies

›Glucose

›Low value in secondary peritonitis or malignancy

›Low value in TB peritonitis

›LDH

›High value in secondary peritonitis or malignancy

›Runyon criteria component

›Gram stain

›Polymicrobial organisms suggest secondary peritonitis

›Yeast suggests fungal peritonitis

Interpretation pitfalls

›PMN threshold nuance

›Antibiotic pretreatment can sterilize cultures

›Culture-negative neutrocytic ascites remains SBP

›Treat based on PMN threshold

›Bacterascites management depends on symptoms

›Symptomatic bacterascites treated as SBP

›Asymptomatic bacterascites may be observed with repeat tap

06Diagnostic Tests/dt49

Scoring Systems

›Severity and prognosis tools

›MELD-Na for cirrhosis severity

›Higher score correlates with SBP mortality risk

›Transplant referral relevance

›ACLF criteria consideration

›Organ failures count

›Short-term mortality risk

›Infection response and risk

›qSOFA limitations in cirrhosis

›Baseline hypotension confounding

›Baseline encephalopathy confounding

›Sepsis-3 with clinical judgment

›Lactate trend supportive

›Vasopressor requirement supportive

MRI

›Limited role in acute SBP

›MRCP if suspected biliary obstruction

›Cholestatic labs pattern

›Dilated ducts on ultrasound

›Liver MRI not time-critical for SBP

›HCC evaluation outpatient pathway

›Not a substitute for paracentesis

›Indications for CT abdomen and pelvis with IV contrast

›Secondary peritonitis concern

›Peritoneal signs

›Runyon criteria met

›Lack of improvement by 48 hours

›Persistent fever

›Rising PMN on repeat tap

›Key CT targets

›Perforation signs

›Free air

›Extraluminal contrast

›Intra-abdominal source

›Abscess

›Appendicitis

›Bowel ischemia

›Pneumatosis

›Portal venous gas

Ultrasound

›Bedside applications

›Paracentesis guidance

›Pocket identification

›Avoid bowel and vessels

›Sepsis evaluation adjuncts

›IVC assessment for volume tolerance

›POCUS for pleural effusions

›Hepatobiliary ultrasound triggers

›RUQ pain or cholestatic labs

›Cholecystitis evaluation

›Bile duct dilation evaluation

07Disposition/dispo25

Level of care decisions

›Admission default

›All suspected or confirmed SBP

›IV antibiotics requirement

›Renal monitoring requirement

›ICU criteria

›Septic shock

›Vasopressors required to maintain MAP at least 65 mmHg

›Lactate persistently elevated

›Rapid clinical deterioration

›Worsening encephalopathy

›Progressive respiratory failure

›Transfer criteria

›Need for higher-level liver care

›ACLF

›Transplant center evaluation

›Suspected secondary peritonitis needing surgery not available locally

›Perforation on CT

›Drainable abscess needing IR not available

Reassessment milestones

›48-hour response check

›Clinical response

›Defervescence

›Improved abdominal pain

›Repeat paracentesis for poor response

›PMN decrease expected

›Failure suggests resistant organism or secondary peritonitis

08Treatment/t86

Empiric antimicrobials

›Initial empiric strategy

›Community-acquired SBP without recent broad-spectrum exposure

›Third-generation cephalosporin pathway

›Cefotaxime IV 2 g every 8 hours

›Typical duration 5 days

›Extend if bacteremia or slow response

›Ceftriaxone IV 2 g once daily

›Typical duration 5 days

›Extend if bacteremia or slow response

›Health care associated or nosocomial SBP

›Broader coverage based on local antibiogram

›Piperacillin-tazobactam IV 4.5 g every 6 to 8 hours

›Avoid if prior ESBL colonization suspected without additional coverage

›De-escalate when cultures available

›Meropenem IV 1 g every 8 hours

›ESBL risk

›De-escalate when cultures available

›Add vancomycin if MRSA risk or prior MRSA colonization

›Vancomycin IV 15 to 20 mg/kg per dose

›Trough guided dosing per institutional protocol

›Severe beta-lactam allergy

›Alternative regimen

›Ciprofloxacin IV 400 mg every 12 hours

›Avoid if on fluoroquinolone prophylaxis

›QT risk monitoring

›Add vancomycin if MRSA risk

›Weight-based dosing

›Renal monitoring

Albumin to prevent hepatorenal syndrome

›Indication-based albumin

›High-risk features

›Creatinine at least 88 micromol/L

›BUN at least 10.7 mmol/L

›Bilirubin at least 68 micromol/L

›Dosing protocol

›Day 1 albumin 1.5 g/kg IV

›Use actual body weight unless extreme obesity

›Infuse in divided doses if volume intolerance

›Day 3 albumin 1.0 g/kg IV

›Hold or reduce if pulmonary edema

›Diuretics pause if intravascular depletion suspected

Supportive care and complication management

›Volume and shock management

›Balanced crystalloid cautious use

›Small boluses with reassessment

›Avoid large-volume saline

›Vasopressor pathway

›Initiate norepinephrine for persistent hypotension after fluids

›Titrate to MAP at least 65 mmHg

›Add vasopressin if escalating norepinephrine needs

›Renal protection

›Nephrotoxin avoidance

›NSAIDs avoidance

›IV contrast risk-benefit discussion

›Diuretics hold during AKI or shock

›Spironolactone hold

›Furosemide hold

›Encephalopathy management if present

›Lactulose

›20 to 30 g PO or via NG tube every 1 to 2 hours until first bowel movement

›Titrate to 2 to 3 soft stools daily

›Rifaximin adjunct

›550 mg PO twice daily

›Add if recurrent encephalopathy

Prophylaxis after an SBP episode

›Secondary prophylaxis

›Fluoroquinolone option

›Ciprofloxacin 500 mg PO daily

›Local resistance consideration

›TMP-SMX option

›TMP-SMX DS 1 tablet PO daily

›Hyperkalemia monitoring

›Primary prophylaxis in selected high-risk patients

›Low ascitic protein with advanced liver disease or renal dysfunction

›Ascitic protein less than 15 g/L

›Child-Pugh C or high MELD

›Acute upper GI bleed prophylaxis

›Ceftriaxone IV 1 g daily for 7 days

›Higher efficacy than norfloxacin in high resistance settings

Evidence grading

›Guideline alignment

›AASLD and EASL support early diagnostic paracentesis and empiric antibiotics in suspected SBP

›Class I recommendation based on guideline consensus

›Time-to-paracentesis associated with outcomes

›Albumin with SBP plus renal dysfunction markers reduces renal failure and mortality

›Class I recommendation in guideline-based practice

›Benefit greatest in high-risk biochemical profiles

›ACEP evidence level mapping not directly available for SBP guideline statements

›Use ACEP Level C label only for ED process steps when local policy adopts them

›Do not treat ACEP levels as primary SBP evidence source

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Cirrhosis and ascites in pregnancy uncommon but high-risk

›Maternal sepsis risk

›Fetal compromise risk

›Antibiotic selection safety

›Ceftriaxone acceptable in pregnancy

›Avoid fluoroquinolones for routine prophylaxis when alternatives available

›Obstetric coordination

›Fetal monitoring if viable gestational age

›Maternal hemodynamics prioritized for fetal perfusion

Geriatric

›Older adult considerations

›Atypical infection presentation

›Afebrile sepsis

›Delirium dominant presentation

›Higher AKI susceptibility

›Lower renal reserve

›Medication accumulation risk

›Antibiotic dosing adjustments

›Renal dose adjustment for vancomycin and TMP-SMX

›QT risk higher with fluoroquinolones

Pediatrics

›Pediatric considerations

›Pediatric cirrhosis with ascites uncommon

›Biliary atresia history

›Metabolic liver disease history

›Diagnostic threshold

›PMN at least 250 cells/mm3 same diagnostic criterion

›Smaller sample volumes acceptable with bedside culture bottles when possible

›Antibiotic dosing weight-based

›Cefotaxime 50 mg/kg IV every 6 to 8 hours

›Ceftriaxone 50 mg/kg IV daily

10Background/b31

Epidemiology

›Epidemiology overview

›SBP frequency in cirrhosis with ascites

›Significant inpatient complication

›Recurrence common without prophylaxis

›Mortality risk

›High short-term mortality despite therapy

›Worse outcomes with shock or AKI

Pathophysiology

›Mechanisms

›Bacterial translocation from gut

›Increased intestinal permeability

›Altered gut microbiome

›Impaired host defenses in cirrhosis

›Reduced complement in ascitic fluid

›Cirrhosis-associated immune dysfunction

›Hemodynamic vulnerability

›Splanchnic vasodilation

›Effective arterial hypovolemia leading to AKI risk

Therapeutic Considerations

›Antibiotic strategy rationale

›Third-generation cephalosporins cover common Gram-negative enteric organisms

›E coli predominance in community cases

›Streptococcal species also common

›Nosocomial resistance patterns

›ESBL risk in recent antibiotic exposure

›Enterococcus and MRSA considerations in selected settings

›Albumin rationale

›Plasma expansion and circulatory support

›Improves effective arterial volume

›Reduces HRS development risk

›Anti-inflammatory binding effects proposed

›Endotoxin binding

›Oxidative stress buffering

11Patient Discharge Instructions/pdi17

copy discharge instructions

›Discharge instructions

›Typical course

›Admission is standard for SBP treatment

›Oral antibiotics at home only if directed by specialist after stabilization

›Medications

›Take prescribed prophylaxis exactly as directed if started

›Avoid NSAIDs unless clinician specifically approves

›Return immediately for

›Fever

›Worsening abdominal pain

›Increasing confusion

›Vomiting blood or black stools

›New severe weakness or fainting

›Follow-up

›Hepatology or gastroenterology follow-up within 1 to 2 weeks after discharge

›Ascites plan review

›Prophylaxis plan review

12References/r22

Clinical guidelines and evidence sources

›Guideline sources

›AASLD practice guidance on ascites and SBP

›Diagnostic paracentesis recommendations

›Antibiotic and albumin recommendations

›EASL clinical practice guidelines for decompensated cirrhosis

›SBP diagnostic threshold and management

›Prophylaxis recommendations

›Landmark evidence

›Albumin plus antibiotics trials in SBP

›Reduced renal impairment

›Reduced mortality in high-risk subgroups

›Bedside inoculation studies for ascitic culture yield

›Higher positivity rates

›Better organism identification

›Decision support and definitions

›Runyon criteria for secondary peritonitis

›Ascitic protein

›Ascitic glucose

›Ascitic LDH

›Sepsis-3 definitions for septic shock

›Vasopressor requirement for MAP targets

›Lactate elevation

Learn More: Spontaneous bacterial peritonitis→

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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