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Spontaneous Bacterial Peritonitis Management (AASLD 2021)

Spontaneous Bacterial Peritonitis Management (AASLD 2021): Suspected SBP: adult with cirrhosis and ascites → Diagnostic paracentesis now, before antibio...

Pathway Overview

20 steps

Algorithm Steps

20 total

  1. 01Start

    Suspected SBP: adult with cirrhosis and ascites

    Any of: fever, abdominal pain or tenderness, encephalopathy, AKI, GI bleeding, shock, or any unplanned admission. SBP can have no symptoms.

  2. 02Action

    Diagnostic paracentesis now, before antibiotics

    Do not delay it. In sepsis or septic shock, give antibiotics at once and do not wait for the tap.

    • Ascitic cell count with differential (neutrophils) and total protein
    • Inoculate blood culture bottles with ascitic fluid at the bedside
    • Blood cultures before antibiotics
    • Add glucose, LDH and Gram stain if secondary peritonitis is possible
    • Do not routinely check INR or platelets or give blood products before the tap
  3. 03Decision

    Ascitic neutrophils (PMN) 250 cells/mm³ or more?

    Yes = SBP, whether the culture is positive or negative. Bloody tap: subtract 1 PMN for every 250 red cells/mm³ before you decide.

  4. If Yes
    1. PMN 250 or more
    2. 04Decision

      PMN 250 or more: is secondary peritonitis suspected?

      Suspect it if 2 or more of: ascitic protein above 10 g/L, glucose below 2.8 mmol/L, LDH above the serum upper limit. Also suspect it with several organisms on Gram stain or culture, localised signs, or a very high PMN.

    3. If Yes
      1. Suspected
      2. 05Warning

        Secondary peritonitis suspected: urgent CT and surgical review

        A surgical source (perforation or abscess) needs source control. Treat as surgical sepsis.

        • Urgent CT abdomen and pelvis
        • Broad-spectrum IV antibiotics with anaerobic cover (local protocol)
        • Early surgical review for source control
      3. 06Outcome

        Secondary peritonitis: surgical and critical care

        Surgical team leads source control. Avoid nephrotoxins and treat AKI. If CT and surgical review find no surgical source, treat as SBP, including IV albumin.

      If No
      1. SBP
      2. 07Warning

        SBP to treat: check allergy and kidneys first

        Applies to SBP, to bacterascites with signs of infection, and to signs of infection with culture pending. Adult doses. Do not delay the first dose.

        • Severe beta-lactam allergy: seek ID advice; IV ciprofloxacin is an option if not on quinolone prophylaxis
        • Do not use aminoglycosides: high risk of AKI in cirrhosis
        • Adjust antibiotic doses for kidney function
      3. 08Decision

        Community-acquired, low resistance risk and no sepsis?

        No if any: onset more than 48 h after admission (nosocomial); recent healthcare contact (healthcare-associated); recent broad-spectrum antibiotics; known MDRO colonisation; sepsis or septic shock.

      4. If Yes
        1. Community-acquired
        2. 09Action

          Community-acquired, low resistance risk: third-generation cephalosporin

          No sepsis, no recent healthcare contact or antibiotics, no known MDRO. Start now.

          • Ceftriaxone 2 g IV daily
          • Or cefotaxime 2 g IV 8-hourly
          • If local resistance to cephalosporins is high: piperacillin-tazobactam or a carbapenem
          • Duration 5 to 7 days
        3. 10Action

          All SBP: IV albumin to prevent AKI (HRS)

          Adults. Watch for fluid overload, most of all with heart disease: if breathless, SpO2 falls or lungs are wet, slow or stop and get senior advice.

          • Albumin 20%: 1.5 g/kg IV within 6 h of diagnosis (day 1)
          • Then 1 g/kg IV on day 3
          • Use estimated dry weight. Guidelines set no maximum: use the local cap
          • Greatest benefit if creatinine 88 µmol/L or more, or bilirubin 68 µmol/L or more
        4. 11Action

          All SBP: protect the kidneys

          AKI develops in up to 30% of patients with SBP.

          • Stop NSAIDs; avoid IV contrast and aminoglycosides where possible
          • Hold non-selective beta-blockers during SBP, above all if systolic BP below 90 mmHg or AKI; try to restart after recovery
          • Hold diuretics during AKI
          • Large-volume paracentesis is not contraindicated but raises AKI risk: only if needed, with albumin 8 g per litre removed
        5. 12Decision

          At 48 h: clinically better and ascitic PMN down by 25% or more?

          Repeat the diagnostic tap at 48 h, always if the response is unclear or secondary peritonitis is possible.

        6. If Yes
          1. Responding
          2. 13Action

            Responding at 48 h: complete 5 to 7 days

            Continue treatment and give the day 3 albumin dose.

            • De-escalate to culture and susceptibility results
            • Step down to oral antibiotics when stable, guided by culture
          3. 14Action

            After recovery from SBP: long-term secondary prophylaxis

            Continue while ascites persists or until liver transplant.

            • Norfloxacin 400 mg orally daily
            • Or trimethoprim-sulfamethoxazole 160/800 mg orally daily
            • Or ciprofloxacin 500 mg orally daily
            • TMP-SMX with spironolactone or kidney impairment: check potassium
            • Stop PPIs that have no clear indication
            • Primary prophylaxis (no SBP before) is no longer routine in Australia (GESA 2026). GI bleeding still needs short-term antibiotic prophylaxis
          4. 15Action

            Refer for liver transplant assessment

            SBP marks decompensated cirrhosis with poor survival (30-50% at 1 year). Refer eligible patients. SBP is not a MELD exception.

          5. 16Outcome

            SBP treated: ongoing cirrhosis care

            Continue prophylaxis and hepatology follow-up.

          If No
          1. Not responding
          2. 17Warning

            Not responding at 48 h: treatment failure

            PMN fall below 25% or clinical worsening. Suspect resistant bacteria or secondary peritonitis.

            • Broaden antibiotics by culture, or empirically (carbapenem with or without a glycopeptide or daptomycin)
            • Urgent CT abdomen and surgical review for secondary peritonitis
            • Seek ID advice; consider ESBL, VRE and fungal peritonitis
          3. Path rejoins step 14Shared downstream outcome
        If No
        1. High risk or sepsis
        2. 18Action

          High resistance risk or sepsis: broader empiric antibiotics

          Choose by setting, severity and local resistance data. Start now. Sepsis or shock: resuscitate by the sepsis pathway and get ICU review.

          • Nosocomial, or high local MDRO rates: carbapenem (for example meropenem)
          • Healthcare-associated with low local MDRO rates: piperacillin-tazobactam
          • Add daptomycin, a glycopeptide or linezolid if MDR gram-positive risk (for example VRE) or sepsis
          • Doses: local protocol or eTG. De-escalate when culture results return
        3. Path rejoins step 10Shared downstream outcome
    If No
    1. PMN below 250
    2. 19Decision

      PMN below 250: signs of infection, with culture positive or pending?

      Signs: fever, abdominal pain or tenderness, encephalopathy, AKI or shock. Culture takes 24 to 48 h: with these signs and no other source, treat as SBP now and review when the culture returns.

    3. If Yes
      1. Treat as SBP
      2. Path rejoins step 07Shared downstream outcome
      If No
      1. Not SBP now
      2. 20Outcome

        PMN below 250, no signs or another source found: not SBP now

        Treat any other infection now; do not wait for the ascitic culture. If the ascitic culture grows bacteria, repeat the tap; treat if it grows again or PMN is 250 or more.

Guideline Source

Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the AASLD (Biggins et al., Hepatology 2021;74:1014-1048)

DOI: 10.1002/hep.31884View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults only. Choose antibiotics by local resistance data and eTG; broad-spectrum doses are not shown.
  • Covers an SBP episode and its prophylaxis. Antibiotic prophylaxis in GI bleeding and HRS-AKI treatment need their own pathways.
  • Albumin: guidelines set no maximum dose; use estimated dry weight and the local cap.
  • Norfloxacin supply in Australia can vary; TMP-SMX or ciprofloxacin are alternatives.

Contraindicated Populations

Children (adult doses only)Peritonitis in peritoneal dialysis

Applicable Regions

AUUSEUGlobal

AU: GESA 2026: primary SBP prophylaxis no longer recommended; secondary prophylaxis norfloxacin 400 mg daily or TMP-SMX 160/800 mg daily. Norfloxacin 400 mg tablets are on the ARTG. Check eTG and local antibiogram for empiric choice.

EU: EASL 2018 decompensated cirrhosis guideline; UK: BSG/BASL 2020 ascites guideline. Both advise empiric choice by setting and local resistance.

US: AASLD 2021 practice guidance. Norfloxacin is not marketed in the US; ciprofloxacin or TMP-SMX are used for prophylaxis.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Spontaneous Bacterial Peritonitis Management (AASLD 2021)?

The Spontaneous Bacterial Peritonitis Management (AASLD 2021) is a emergency clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the AASLD (Biggins et al., Hepatology 2021;74:1014-1048).

What guideline is the Spontaneous Bacterial Peritonitis Management (AASLD 2021) based on?

This algorithm is based on Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the AASLD (Biggins et al., Hepatology 2021;74:1014-1048) (DOI: 10.1002/hep.31884).

What are the limitations of the Spontaneous Bacterial Peritonitis Management (AASLD 2021)?

Known limitations include: Adults only. Choose antibiotics by local resistance data and eTG; broad-spectrum doses are not shown.; Covers an SBP episode and its prophylaxis. Antibiotic prophylaxis in GI bleeding and HRS-AKI treatment need their own pathways.; Albumin: guidelines set no maximum dose; use estimated dry weight and the local cap.; Norfloxacin supply in Australia can vary; TMP-SMX or ciprofloxacin are alternatives.. Individual patient factors may require deviation from these recommendations.

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