Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis
Prof. Dr. med. J. Reichen

This is a compilation of a consensus document of the International Ascites club and has been published: Rimola A et al. (2000); J. Hepatol. 32: 142-153. The original references can be found in this review article.

Prevalence and prognosis
  • 10 - 30 % in hospitalized patients
  • One year survival after first episode of SBP 30 - 50 %
  • Corresponding two year survival 25 - 30 %
    		•  
    Diagnostic measures Paracentesis under the following conditions
    • At hospital admission
    • Signs and symptoms of SBP
    • Prior to antibiotic prophylaxis for GI bleeding

    Diagnosis is made if PMN > 250/ml
    Culture at bedside (minimal 20 ml)

    		 Rating

    AB, III
    AB, III
    B, II

    B, III
    B, I
    Treatment
    1. Empiric therapy if PMN > 250/ml
    2. Recommended antibiotics:
      Cefotaxim minimal 2 g/12 x 5 days
      Other 3rd generation cephalosporins
      Amoxycillin/clavulanic acid
      Oral ofloxacin in uncomplicated SBP
      Quinolones for b-lactam hypersensitive patients
      Avoid aminoglyosides
    3. Assessment of response:
      At least one f/u paracentesis
      Treatment failure when clinical deterioration and/or
      < 25 % in PMN count in f/u paracentesis
    4. Treatment failure: consider 2° peritonitis
      Modify antiobiotic therapy
    		 A, II

    A, I
    AE, II
    AE, II
    AE, II
    A, IV
    A, I

    AB, III
    A, IV
     
     

     
    Prophylaxis
    • In cirrhotics with UGI bleed
      1. Oral norfloxacin 400 mg/12 h for 7 d
      2. Alternatives: amoxycillin/clavulanic acid
      3. R/o SBP before treatment
    • In patients recovering from SBP
      Continuous norfloxacin 400 mg p.o. daily
      Consider OLT
    • Patients without history of SBP:


      • Ascites protein > 10 g/l: no prophylaxis
      Ascites protein < 10 g/l: no consensus

    AE, I
    A, II
    A, III

    AE, I
    AC, III

    E, III
    IV

     

    Rating:

     

    A

    Survival benefit

    I

    Evidence from at least one RCT

    B

    Improved diagnosis

    		 II Evidence from at least one trial without randomization, cohort/case control study or well designed metaanalysis
    C Improved quality of life III Evidence from clinical experience, descriptive studies or reports of expert committees
    D Improved pathophysiological knowledge IV No rating
    E Impact on health care cost