Management of Spontaneous Bacterial Peritonitis

Diagnosis and Treatment

The European Association for the Study of the Liver recommends immediate treatment with third-generation cephalosporins such as cefotaxime 2g IV every 8 hours for 5 days plus intravenous albumin (1.5 g/kg at diagnosis and 1 g/kg on day 3) for spontaneous bacterial peritonitis (SBP) with 11,000 white blood cells (WBC) in paracentesis fluid 1, 2
A neutrophil count >250/mm³ in ascitic fluid confirms SBP diagnosis, with 11,000 WBC representing a severe infection requiring prompt treatment 1, 2
Although ascitic fluid culture is not necessary for diagnosis, it should be performed to guide antibiotic therapy 1, 3
Blood cultures should be obtained before starting antibiotics to identify potential bacteremia 1, 2
Initiate empirical antibiotics immediately upon diagnosis without waiting for culture results 1, 4
Third-generation cephalosporins are the first-line treatment, with cefotaxime 2g IV every 6-8 hours for 5 days being a recommended option 1, 5
A 5-day therapy is as effective as a 10-day treatment 4, 5
Intravenous albumin (1.5 g/kg at diagnosis, followed by 1 g/kg on day 3) significantly reduces the risk of hepatorenal syndrome and mortality 6

Perform a repeat paracentesis after 48 hours of treatment to assess response 4, 6
Treatment failure is defined as failure of ascitic neutrophil count to decrease by at least 25% of the pre-treatment value or worsening of clinical signs and symptoms 4, 6
If treatment fails, consider resistant bacteria requiring antibiotic change based on culture results or secondary bacterial peritonitis requiring surgical evaluation 4, 6, 7, 8

SBP has approximately 20% hospital mortality rate despite infection resolution 6
Early appropriate antibiotic treatment combined with albumin therapy significantly improves survival 6