Guideline sources The following summarized guidelines for the evaluation and management of spontaneous bacterial peritonitis are prepared by our editorial team based on guidelines from the Society of Critical Care Medicine (SCCM 2023), the British Association for the Study of the Liver (BASL/BSG 2021), the American Association for the Study of Liver Diseases (AASLD 2021), the European Association for the Study of the Liver (EASL 2018), and the American College of Gastroenterology (ACG/AASLD 2007). 1 2 3 4 5 CalculatorDiagnostic criteria for spontane Guidelines https://web.pathway.md/diseases/recFbL35doOPnLvee 1/6 6/24/23, 3:14 PM Spontaneous bacterial peritonitis Pathway 1. Screening and diagnosis Diagnostic criteria: As per AASLD 2021 guidelines, establish the diagnosis of SBP with a fluid polymorphonuclear leukocyte count > 250/mm . E As per BSG 2021 guidelines, use ascitic neutrophil > 250/mm count as the gold standard for the diagnosis of SBP. Consider measuring ascitic neutrophil count either by manual microscopy or using flow cytometry-based automated methods for counting and differentiating cells. B As per EASL 2018 guidelines, diagnose SBP in the presence of > 250/mm neutrophils (counted by microscopy or using a flow cytometry-based automated count) in ascitic fluid. B Show 2 more 2. Diagnostic investigations Blood culture: as per EASL 2018 guidelines, obtain blood cultures in all patients with suspected SBP before antibiotic treatment initiation. B Abdominal computed tomography: obtain prompt CT and consider performing early surgery in patients with suspected secondary bacterial peritonitis. B 3. Diagnostic procedures Diagnostic paracentesis: As per AASLD 2021 guidelines, perform diagnostic abdominal paracentesis to rule out SBP in patients with ascites due to cirrhosis emergently admitted to the hospital, even in the absence of symptoms/signs of infection. E Show 3 more As per BSG 2021 guidelines, perform diagnostic paracentesis without a delay to rule out SBP in all patients with cirrhosis and ascites on hospital admission. B Show 3 more As per EASL 2018 guidelines, perform diagnostic paracentesis in all patients with cirrhosis and ascites without delay at hospital admission to rule out SBP. B Show 3 more 4. Medical management Antibiotic therapy: As per AASLD 2021 guidelines, initiate empiric IV antibiotics in all patients with an ascites/pleural fluid polymorphonuclear count > 250/mm . E Show 2 more https://web.pathway.md/diseases/recFbL35doOPnLvee 2/6 6/24/23, 3:14 PM Spontaneous bacterial peritonitis Pathway As per BSG 2021 guidelines, initiate immediate empirical antibiotic therapy with due consideration of the context of SBP (community-acquired or healthcare-associated), severity of infection, and local bacterial resistance profile. Guide the choice of an antibiotic agent by local resistance patterns and protocols. B As per EASL 2018 guidelines, initiate empiric IV antibiotics immediately after the diagnosis of SBP. B Show 5 more Intravenous albumin: As per AASLD 2021 guidelines, administer IV albumin in addition to antibiotics (1.5 g/kg on day 1 and 1 g/kg on day 3) in patients with SBP, especially in the presence of AKI and/or jaundice at the time of SBP diagnosis. E As per BSG 2021 guidelines, administer albumin (1.5 g/kg infusion within 6 hours of diagnosis followed by 1 g/kg on day 3) in patients with SBP and increased or rising serum creatinine. B As per EASL 2018 guidelines, administer albumin (1.5 g/kg at diagnosis and 1 g/kg on day 3) in patients with SBP. A Medications to avoid: As per AASLD 2021 guidelines: Avoid using aminoglycosides, wherever possible, for the treatment of bacterial infections in patients with cirrhosis and ascites. D Discontinue nonselective -blockers temporarily in patients with SBP developing hypotension (mean arterial pressure < 65 mmHg) or AKI. E As per EASL 2018 guidelines: Discontinue nonselective -blockers in patients with SBP. B Attempt reinitiating nonselective -blockers after recovery. B Restrict the use of PPIs to patients with a clear indication, since they may increase the risk of SBP in patients with prior SBP. B 5. Surgical interventions Liver transplantation: consider performing liver transplantation in patients recovered from SBP, given the poor long-term survival. B 6. Specific circumstances Pediatric patients: Perform diagnostic paracentesis in pediatric patients with ascites and fever, abdominal pain or clinical deterioration. Insufficient evidence to recommend diagnostic paracentesis in all pediatric patients with new ascites but without these symptoms. E https://web.pathway.md/diseases/recFbL35doOPnLvee 3/6 6/24/23, 3:14 PM Spontaneous bacterial peritonitis Pathway Initiate broad-spectrum antibiotics against both gram-positive and gram-negative organisms in pediatric patients with proven and suspected SBP. E Patients with bacterascites: Initiate antibiotics in patients with bacterascites (neutrophil count < 250/mm but positive bacterial culture) exhibiting signs of systemic inflammation or infection. B Perform a second paracentesis in patients with bacterascites as an alternative strategy to antibiotic therapy. Initiate treatment if the culture results come back positive again regardless of the neutrophil count. B Patients with acute-on-chronic liver failure: administer albumin in critically ill patients with acute-on-chronic liver failure and SBP. B Show 3 more 7. Preventative measures Primary prevention, gastrointestinal hemorrhage: As per AASLD 2021 guidelines, administer antibiotic prophylaxis for SBP in patients with cirrhosis and upper gastrointestinal hemorrhage. Administer IV ceftriaxone 1 g/24 hours as the antibiotic of choice for a maximum of 7 days. E As per BASL/BSG 2021 guidelines, administer prophylactic antibiotic treatment (chosen based on local data) to prevent the development of SBP in patients presenting with gastrointestinal bleeding and underlying ascites due to cirrhosis. A As per ACG/AASLD 2007 guidelines, administer short-term (maximum 7 days) antibiotic prophylaxis to prevent infectious complications, including SBP, in any patient with cirrhosis and gastrointestinal hemorrhage. A Show 2 more Landmark trials: Ceftriaxone prophylaxis in cirrhosis with GI bleeding In patients with advanced cirrhosis (at least 2 of the following: ascites, severe malnutrition, encephalopathy, or bilirubin > 3 mg/dL) and gastrointestinal hemorrhage, ceftriaxone was superior to norfloxacin with respect to proved or possible infections at 10 days. Fernandez J et al. Gastroenterology. 2006 Oct. Primary prevention, advanced liver disease: As per AASLD 2021 guidelines, consider administering primary prophylaxis for SBP in selected patients with cirrhosis and low protein (< 1.5 g/L) ascites and renal dysfunction (serum creatinine level > 1.2 mg/dL, BUN level > 25 mg/dL or serum sodium level < 130 mEq/L) or liver failure (Child-Turcotte-Pugh score > 9 and bilirubin > 3 mg/dL). E As per BASL/BSG 2021 guidelines, administer primary prophylaxis for SBP in high-risk patients, as defined by an ascitic protein count < 1.5 g/dL, with a discussion of potential risks and benefits https://web.pathway.md/diseases/recFbL35doOPnLvee 4/6 6/24/23, 3:14 PM Spontaneous bacterial peritonitis Pathway and existing uncertainties with patients. B Secondary prevention: As per AASLD 2021 guidelines, initiate long-term prophylaxis with daily norfloxacin in patients recovered from an episode of SBP. Consider initiating oral ciprofloxacin if norfloxacin is unavailable. E As per BSG 2021 guidelines, consider initiating norfloxacin (400 mg once daily), ciprofloxacin (500 mg once daily, PO), or co-trimoxazole (800 mg sulfamethoxazole and 160 mg TMP daily, PO) to prevent further episodes of SBP in patients recovered from an episode of SBP. C As per EASL 2018 guidelines: Initiate prophylactic norfloxacin (400 mg/day, PO) in patients recovered from an episode of SBP. A Insufficient evidence to support the use of rifaximin as an alternative to norfloxacin for secondary prophylaxis of SBP. I 8. Follow-up and surveillance Assessment of treatment response: As per AASLD 2021 guidelines, consider assessing the response to empirical antibiotic therapy by repeating diagnostic paracentesis 2 days after treatment initiation. Broaden antibiotic coverage and obtain a further evaluation to rule out secondary bacterial peritonitis if a decrease in fluid polymorphonuclear is < 25% from baseline indicating a lack of response. E As per BSG 2021 guidelines, consider performing a second diagnostic paracentesis at 48 hours from the start of treatment to check the efficacy of antibiotic therapy in patients with apparent inadequate response or if secondary bacterial peritonitis is suspected. C As per EASL 2018 guidelines, perform a second paracentesis at 48 hours from treatment initiation to check the efficacy of antibiotic therapy. Suspect failure of first-line antibiotic therapy if there is worsening of clinical signs and symptoms and/or increase or no marked reduction in leucocyte count (at least 25%) in 48 hours. B Likelihood Ratios Pertinent positives The following findings increase the probability of spontaneous bacterial peritonitis in adults. -1 Finding LR+ Value Increased gradient of blood pH to ascites pH ( 0.10) 11.3 (4.3-29.9) Increased ascites fluid WBC count (> 1,000 cells/ L) 9.1 (5.5-15.0) Decreased ascites fluid pH (< 7.35) 9.0 (2.0-40.6) 6.4 (4.6-8.8) https://web.pathway.md/diseases/recFbL35doOPnLvee 5/6 6/24/23, 3:14 PM Spontaneous bacterial peritonitis Pathway Increased ascites fluid PMN leukocyte count (> 250 cells/ L) Pertinent negatives The following findings decrease the probability of spontaneous bacterial peritonitis in adults. -1 Finding LR- Value gradient of blood pH to ascites pH not increased (< 0.10) 0.12 (0.02-0.77) ascites fluid PMN leukocyte count not increased ( 250 cells/ L) 0.20 (0.11-0.37) ascites fluid WBC count not increased ( 1,000 cells/ L) 0.25 (0.13-0.48) ascites fluid pH not decreased ( 7.35) 0.31 (0.11-0.84) References 1. Garcia-Tsao G, Sanyal AJ, Grace ND et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007 Sep;46 3 922 38. Open 2. Guruprasad P Aithal, Naaventhan Palaniyappan, Louise China et al. Guidelines on the management of ascites in cirrhosis. Gut. 2021 Jan;70 1 9 29. Open 3. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018 Aug;69 2 406 460. Open 4. Scott W Biggins, Paulo Angeli, Guadalupe Garcia-Tsao et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Aug;74 2 1014 1048. Open 5. Rahul Nanchal, Ram Subramanian, Waleed Alhazzani et al. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations. Crit Care Med. 2023 May 1;51 5 657 676. Open 6. European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010 Sep;53 3 397 417. Open https://web.pathway.md/diseases/recFbL35doOPnLvee 6/6