Spontaneous Bacterial Peritonitis Management (AASLD 2021)

Algorithm Steps

1. ▶

   Start

   Suspected SBP

   Cirrhosis + ascites + (fever, abdominal pain, encephalopathy, renal dysfunction, or leukocytosis)

   1. ●

      Action

      Diagnostic Paracentesis

      Perform BEFORE antibiotics if possible

      • Send: cell count with diff, culture (bedside inoculation)
      • Also: protein, albumin, glucose, LDH
      • Blood cultures x2
      • No contraindication if INR or platelets abnormal
      1. ◆

         Decision

         SBP Diagnosis

         Ascitic fluid PMN ≥250 cells/mm³

         • Culture-positive or culture-negative SBP
         • Monomicrobial non-neutrocytic bacterascites (MNB): +culture, PMN <250
         1. ◆

            Decision

            Rule Out Secondary Peritonitis

            Runyon's criteria (≥2 of 3)

            • Ascitic protein >1 g/dL
            • Glucose <50 mg/dL
            • LDH > upper limit of serum
            • Polymicrobial culture
            • If suspected: CT abdomen, surgical consult
            1. ⚠

               Warning

               ⚠️ Secondary Peritonitis

               Urgent surgical evaluation

               • Broad-spectrum antibiotics
               • CT abdomen/pelvis
               • Surgical source control
            2. ●

               Action

               Empiric Antibiotic Therapy

               Start immediately after paracentesis

               • Cefotaxime 2g IV q8h (preferred)
               • OR Ceftriaxone 2g IV q24h
               • Duration: 5 days (can extend to 7-10)
               • Avoid aminoglycosides (nephrotoxicity)
               1. ●

                  Action

                  IV Albumin (HRS Prevention)

                  Required if Cr >1 or BUN >30 or bilirubin >4

                  • 1.5 g/kg on Day 1
                  • 1.0 g/kg on Day 3
                  • Reduces HRS and mortality by 60%+
                  • Consider for all hospitalized SBP
                  1. ◆

                     Decision

                     48-Hour Reassessment

                     Repeat paracentesis if no improvement

                     • PMN should decrease by ≥25%
                     • Clinical improvement expected
                     1. ●

                        Action

                        Clinical Improvement

                        Continue antibiotics for 5 days total

                        • Switch to PO if able (fluoroquinolone)
                        • No repeat paracentesis needed if improving
                        1. ●

                           Action

                           Secondary Prophylaxis

                           After SBP episode, lifelong unless transplanted

                           • Norfloxacin 400mg PO daily (preferred)
                           • OR TMP-SMX DS daily
                           • OR Ciprofloxacin 500mg daily
                           • Also primary prophylaxis if: protein <1.5 + (Cr >1.2 OR Na <130 OR Child C)
                           1. ✓

                              Outcome

                              SBP Resolved

                              Continue prophylaxis, optimize cirrhosis management

                           2. ✓

                              Outcome

                              Transplant Evaluation

                              SBP indicates decompensated cirrhosis - MELD exception

                     2. ⚠

                        Warning

                        Treatment Failure

                        Repeat paracentesis, broaden antibiotics

                        • Consider resistant organisms (ESBL, VRE)
                        • Piperacillin-tazobactam or carbapenem
                        • Re-evaluate for secondary peritonitis
                        • Consider fungal infection