Therapeutic Paracentesis in Spontaneous Bacterial Peritonitis
Diagnostic Paracentesis
- The American Association for the Study of Liver Diseases recommends performing diagnostic paracentesis immediately upon hospital admission in all cirrhotic patients with ascites, even without symptoms of infection 3, 4, 5.
- Diagnostic paracentesis must also be performed urgently in patients with fever, shock, GI bleeding, hepatic encephalopathy, worsening liver/renal function, or any signs of systemic inflammation 3, 4, 6.
- Obtain at least 10 mL of ascitic fluid and inoculate blood culture bottles at bedside before starting antibiotics 1, 7.
- Diagnosis requires ascitic fluid polymorphonuclear (PMN) count >250/mm³ 3, 4, 6.
Initial Management
- The European Association for the Study of the Liver recommends starting IV third-generation cephalosporin (cefotaxime 2g q12h or ceftriaxone) immediately after diagnostic tap in community-acquired cases 3, 1, 7.
- Administer IV albumin 1.5 g/kg on day 1 and 1 g/kg on day 3, particularly in patients with creatinine ≥1.0 mg/dL or bilirubin ≥5 mg/dL 1, 2.
Follow-up Paracentesis
- Repeat diagnostic paracentesis 48 hours after initiating antibiotics to assess treatment response 1, 2, 6.
- Treatment failure is defined as <25% decrease in PMN count from baseline, which should prompt broadening antibiotic coverage and CT imaging to exclude secondary bacterial peritonitis 1, 2.