Treatment of Spontaneous Bacterial Peritonitis in Cirrhotic Adults

Immediate Antibiotic Therapy

The American Association for the Study of Liver Diseases recommends initiating intravenous cefotaxime 2 g every 8 hours immediately, and adding albumin infusion to reduce mortality from 29% to 10% 1, 2
First-line antibiotic options include cefotaxime 2 g IV every 8 hours, which is the most studied and preferred option, and ceftriaxone 1-2 g IV every 12-24 hours, which is an equally effective alternative 1, 3, 4, 5
The treatment duration is 5 days if clinical response is adequate and PMN count drops below 250 cells/mm³ 1, 5

Albumin administration dramatically improves survival and must be given concurrently with antibiotics, with a dose of 1.5 g/kg body weight within 6 hours of diagnosis and 1.0 g/kg on day 3 1, 2, 6
Albumin is particularly essential when creatinine ≥1 mg/dL, BUN ≥30 mg/dL, or bilirubin ≥4 mg/dL, and reduces mortality from 29% to 10% (P=0.01) and prevents renal failure (10% vs 33%, P=0.002) 1, 6

Additional ascitic fluid tests, including total protein, LDH, glucose, and Gram stain, should be ordered to exclude surgical peritonitis 3, 4, 5, 6
Secondary peritonitis is suspected if at least 2 of 3 criteria are met: total protein ≥1 g/dL, LDH > upper limit of normal for serum, glucose <50 mg/dL, or if ascitic CEA ≥5 ng/mL or alkaline phosphatase ≥240 U/L 4, 5, 6

Repeat paracentesis is not routinely necessary if the patient has typical SBP, but should be performed at 48 hours if there is an atypical presentation, no clinical improvement, multiple organisms isolated, or concern for secondary peritonitis 3, 4, 5, 6

Delaying treatment waiting for culture results may result in death from overwhelming infection, and empiric therapy should be guided by the PMN count, which is rapidly available 1, 7
Omitting albumin is not recommended, as it specifically reduces mortality and renal failure beyond antibiotic effects alone 1, 2
Assuming all elevated PMN counts are SBP is not accurate, as other conditions such as hemorrhagic ascites, peritoneal carcinomatosis, pancreatitis, and tuberculosis can elevate PMN counts without infection 1, 7
Patients on quinolone prophylaxis require alternative antibiotics, such as cefotaxime or broader coverage, as they likely harbor quinolone-resistant organisms 3, 6