spontaneous bacterial peritonitis

Signs and symptoms of spontaneous bacterial peritonitis (SBP) include fevers, chills, nausea, vomiting, abdominal pain and tenderness, general malaise, altered mental status, and worsening ascites. Thirteen percent of patients have no signs or symptoms. In cases of acute or chronic liver failure SBP is one of the main triggers for hepatic encephalopathy, and where there is no other clear causal indication for this, SBP may be suspected.

These symptoms can also be the same for a spontaneous fungal peritonitis (SFP) and therefore make a differentiation difficult. Delay of diagnosis can delay antifungal treatment and lead to a higher mortality rate.

SBP is most commonly caused by Gram-negative E. coli, followed by Klebsiella. Common Gram-positive bacteria identified include species of Streptococcus, Staphylococcus, and Enterococcus.{{Cite journal|last1=Fiore|first1=Marco|last2=Maraolo|first2=Alberto Enrico|last3=Gentile|first3=Ivan|last4=Borgia|first4=Guglielmo|last5=Leone|first5=Sebastiano|last6=Sansone|first6=Pasquale|last7=Passavanti|first7=Maria Beatrice|last8=Aurilio|first8=Caterina|last9=Pace|first9=Maria Caterina|date=2017-10-28|title=Current concepts and future strategies in the antimicrobial therapy of emerging Gram-positive spontaneous bacterial peritonitis|journal=World Journal of Hepatology|volume=9|issue=30|pages=1166–1175|doi=10.4254/wjh.v9.i30.1166|issn=1948-5182|pmc=5666303|pmid=29109849 |doi-access=free }} The percentage of gram-positive bacteria responsible has been increasing.

A spontaneous fungal infection can often follow a spontaneous bacterial infection that has been treated with antibiotics. The use of antibiotics can result in an excessive growth of fungi in the gut flora which can then translocate into the peritoneal cavity.{{cite journal |last1=Fiore |first1=M |last2=Leone |first2=S |title=Spontaneous fungal peritonitis: Epidemiology, current evidence and future prospective. |journal=World Journal of Gastroenterology |date=14 September 2016 |volume=22 |issue=34 |pages=7742–7 |doi=10.3748/wjg.v22.i34.7742 |pmid=27678356|pmc=5016373 |doi-access=free }} Although fungi are much larger than bacteria, the increased intestinal permeability resulting from advanced cirrhosis makes their translocation easier. SFP is mostly caused by species of Candida and most commonly by Candida albicans.

H₂ antagonists and proton-pump inhibitors are medications that decrease or suppress the secretion of acid by the stomach. Their use in treating cirrhosis is associated with the development of SBP.{{cite journal |vauthors=Gati GA, Deshpande A | title = Increased rate of spontaneous bacterial peritonitis among cirrhotic patients receiving pharmacologic acid suppression | journal = Clinical Gastroenterology and Hepatology | volume = 10 | pages = 422–27 | year = 2012 | pmid = 22155557 | doi=10.1016/j.cgh.2011.11.019 | issue=4| doi-access = free }}{{cite journal |vauthors=Deshpande A, Pasupuleti V | title = Acid suppressive therapy is associated with spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis | journal = Journal of Gastroenterology and Hepatology | doi= 10.1111/jgh.12065 | year = 2012 | pmid = 23190338 | volume=28 | issue=2 | pages=235–42| s2cid = 25099491 }}{{cite journal |vauthors=Bajaj JS, Zadvornova Y | title = Association of Proton Pump Inhibitor Therapy With Spontaneous Bacterial Peritonitis in Cirrhotic Patients With Ascites | journal = American Journal of Gastroenterology | volume = 104 | pages = 1130–34 | year = 2009 | pmid = 19337238 | doi=10.1038/ajg.2009.80 | issue=5| s2cid = 21179465 }} Bacterial translocation is thought to be the key mechanism for the development of SBP.{{cite journal |last1=Koulaouzidis |first1=A |last2=Bhat |first2=S |last3=Saeed |first3=AA |title=Spontaneous bacterial peritonitis. |journal=World Journal of Gastroenterology |date=7 March 2009 |volume=15 |issue=9 |pages=1042–9 |pmid=19266595|pmc=2655193 |doi=10.3748/wjg.15.1042 |doi-access=free }}{{cite journal |last1=Căruntu |first1=FA |last2=Benea |first2=L |title=Spontaneous bacterial peritonitis: pathogenesis, diagnosis, treatment. |journal=Journal of Gastrointestinal and Liver Diseases |date=March 2006 |volume=15 |issue=1 |pages=51–6 |pmid=16680233}} Small intestinal bacterial overgrowth which may be implicated in this translocation, is found in a large percentage of those with cirrhosis.{{cite journal |last1=Maslennikov |first1=R |last2=Pavlov |first2=C |last3=Ivashkin |first3=V |title=Small intestinal bacterial overgrowth in cirrhosis: systematic review and meta-analysis. |journal=Hepatology International |date=4 October 2018 |doi=10.1007/s12072-018-9898-2 |pmid=30284684 |volume=12 |issue=6 |pages=567–576|s2cid=52917740 }}

With respect to compromised host defenses, patients with severe acute or chronic liver disease are often deficient in complement and may also have malfunctioning of the neutrophilic and reticuloendothelial systems.{{cite journal |vauthors=Alaniz C, Regal RE | title = Spontaneous Bacterial Peritonitis: A Review of Treatment Options | journal = P T | volume = 34 | issue = 4 | pages = 204–210 |date=April 2009 | pmid = 19561863 | pmc = 2697093 }}

As for the significance of ascitic fluid proteins, it was demonstrated that cirrhotic patients with ascitic protein concentrations below 1 g/dL were 10 times more likely to develop SBP than individuals with higher concentrations.{{cite journal | author = Runyon BA | title = Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis | journal = Gastroenterology | volume = 91 | issue = 6 | pages = 1343–6 |date=December 1986 | pmid = 3770358 | doi = 10.1016/0016-5085(86)90185-x}}{{Cite journal |last=Ullah |first=Himayat |date=2023-03-29 |title=Relation of Low Ascitic Fluid Proteins with Spontaneous Bacterial Peritonitis (SBP) in Patients with Portosystemic Encephalopathy – A Comparative Study |url=https://medicalforummonthly.com/index.php/mfm/article/view/130 |journal=Medical Forum Monthly |language=en |volume=34 |issue=3 |issn=2519-7134}} It is thought that the antibacterial, or opsonic, activity of ascitic fluid is closely correlated with the protein concentration.{{cite journal |vauthors=Runyon BA, Morrissey RL, Hoefs JC, Wyle FA | title = Opsonic activity of human ascitic fluid: a potentially important protective mechanism against spontaneous bacterial peritonitis | journal = Hepatology | volume = 5 | issue = 4 | pages = 634–7 | year = 1985 | pmid = 4018735 | doi = 10.1002/hep.1840050419| s2cid = 9665518 }} Additional studies have confirmed the validity of the ascitic fluid protein concentration as the best predictor of the first episode of SBP.

In nephrotic syndrome, SBP can frequently affect children but only very rarely can it affect adults.{{cite journal |last1=Ruiz |first1=S |last2=Soto |first2=S |last3=Rodado |first3=R |last4=Alcaraz |first4=F |last5=López Guillén |first5=E |title=[Spontaneous bacterial peritonitis as form of presentation of idiophatic nephrotic syndrome in a black adult]. |journal=Anales de Medicina Interna |date=September 2007 |volume=24 |issue=9 |pages=442–4 |pmid=18198954 |doi=10.4321/s0212-71992007000900008|doi-access=free }}

Infection of the peritoneum causes an inflammatory reaction with a subsequent increase in the number of neutrophils in the fluid. Diagnosis is made by paracentesis (needle aspiration of the ascitic fluid); SBP is diagnosed if the fluid contains neutrophils at greater than 250 cells per mm³ (equals a cell count of 250 x10⁶/L) fluid in the absence of another reason for this (such as inflammation of one of the internal organs or a perforation).{{cite journal |vauthors=Moore KP, Aithal GP |title=Guidelines on the management of ascites in cirrhosis |journal=Gut |volume=55| issue=Suppl 6|pages=vi1–12 |date=October 2006 |pmid=16966752 |pmc=1860002 |doi=10.1136/gut.2006.099580 |url=}}

The fluid is also cultured to identify bacteria. If the sample is sent in a plain sterile container, 40% of samples will identify an organism, while if the sample is sent in a bottle with culture medium, the sensitivity increases to 72–90%.

All people with cirrhosis might benefit from antibiotics (oral fluoroquinolone norfloxacin) if:

• Ascitic fluid protein <1.0 g/dL. Patients with fluid protein <15 g/L and either Child–Pugh score of at least 9 or impaired renal function may also benefit.{{cite journal |vauthors=Fernández J, Navasa M, Planas R, etal |title=Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis |journal=Gastroenterology |volume=133 |issue=3 |pages=818–24 |year=2007 |pmid=17854593 |doi=10.1053/j.gastro.2007.06.065|doi-access=free }}
• Previous SBP{{cite journal |vauthors=Grangé JD, Roulot D, Pelletier G, etal |title=Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites: a double-blind randomized trial |journal=J. Hepatol. |volume=29 |issue=3 |pages=430–6 |year=1998 |pmid=9764990 |doi=10.1016/S0168-8278(98)80061-5}}

People with cirrhosis admitted to the hospital should receive prophylactic antibiotics if:

• They have bleeding esophageal varices{{Cite journal|last1=Chavez-Tapia|first1=Norberto C.|last2=Barrientos-Gutierrez|first2=Tonatiuh|last3=Tellez-Avila|first3=Felix I.|last4=Soares-Weiser|first4=Karla|last5=Uribe|first5=Misael|date=2010-09-08|title=Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding|journal=The Cochrane Database of Systematic Reviews|volume=2010 |issue=9|pages=CD002907|doi=10.1002/14651858.CD002907.pub2|issn=1469-493X|pmid=20824832|pmc=7138054}}

Studies on the use of rifaximin in cirrhotic patients, have suggested that its use may be effective in preventing spontaneous bacterial peritonitis.{{cite journal |last1=Goel |first1=A |last2=Rahim |first2=U |last3=Nguyen |first3=LH |last4=Stave |first4=C |last5=Nguyen |first5=MH |title=Systematic review with meta-analysis: rifaximin for the prophylaxis of spontaneous bacterial peritonitis. |journal=Alimentary Pharmacology & Therapeutics |date=December 2017 |volume=46 |issue=11–12 |pages=1029–1036 |doi=10.1111/apt.14361 |pmid=28994123|doi-access=free }}

Although there is no high-quality evidence, the third-generation cephalosporins are considered the standard empirical treatment for spontaneous bacterial peritonitis in people with cirrhosis.{{cite journal|last1=Chavez-Tapia|first1=NC|last2=Soares-Weiser|first2=K|last3=Brezis|first3=M|last4=Leibovici|first4=L|title=Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients.|journal=The Cochrane Database of Systematic Reviews|date=21 January 2009|volume=2009 |issue=1|pages=CD002232|doi=10.1002/14651858.CD002232.pub2|pmid=19160207|pmc=7100568}}

Other resources mentioned that empiric third-generation cephalosporins are recommended for suspected SBP with a Polymorphonuclear neutrophils (PMN) count over 250 cells/μL. The exception was that if in cases of prior beta-lactam use or hospital-acquired infections, the treatment should be guided by susceptibility testing. Patients with a PMN count above 500 cells/μL require hospitalization and antibiotics, with follow-up ascitic fluid analysis. Lack of improvement within 48 hours may indicate secondary bacterial peritonitis, potentially requiring surgery. A PMN reduction of at least 25% suggests an adequate response to treatment.{{Citation |last=Ameer |first=Muhammad Atif |title=Spontaneous Bacterial Peritonitis |date=2025 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK448208/ |access-date=2025-02-26 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=28846337 |last2=Foris |first2=Lisa A. |last3=Mandiga |first3=Pujyitha |last4=Haseeb |first4=Muhammad}}

In practice, cefotaxime is the agent of choice for treatment of SBP. After confirmation of SBP, hospital admission is usually advised for observation and intravenous antibiotic therapy.{{cite web |url=https://www.nhs.uk/conditions/peritonitis/ |title=Peritonitis |author= |date=October 9, 2020 |website= NHS|publisher=Gov.UK |access-date=February 7, 2023 }}

Where there is a risk of kidney malfunction developing in a syndrome called hepatorenal syndrome, intravenous albumin is usually administered too. Paracentesis may be repeated after 48 hours to ensure control of infection. After recovery from a single episode of SBP, indefinite prophylactic antibiotics are recommended.

The addition of a prokinetic drug to an antibiotic regimen reduces the incidence of spontaneous bacterial peritonitis possibly via decreasing small intestinal bacterial overgrowth.{{Cite journal | last1 = Hiyama | first1 = T. | last2 = Yoshihara | first2 = M. | last3 = Tanaka | first3 = S. | last4 = Haruma | first4 = K. | last5 = Chayama | first5 = K. | title = Effectiveness of prokinetic agents against diseases external to the gastrointestinal tract. | journal = J Gastroenterol Hepatol | volume = 24 | issue = 4 | pages = 537–46 |date=Apr 2009 | doi = 10.1111/j.1440-1746.2009.05780.x | pmid = 19220673 | doi-access = free }}

A randomized controlled trial found that intravenous albumin on the day of admission and on hospital day 3 can reduce kidney impairment.{{cite journal |vauthors=Sort P, Navasa M, Arroyo V, etal |title=Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis |journal=N. Engl. J. Med. |volume=341 |issue=6 |pages=403–9 |year=1999 |pmid=10432325 |doi=10.1056/NEJM199908053410603|doi-access=free }}

With proper treatment, infection-related mortality in SBP is low, but outcomes worsen if sepsis develops. In hospitals, non-infection-related mortality can reach 20–40%, while one- and two-year mortality rates are approximately 70% and 80%, respectively.{{Cite journal |last=Li |first=Hanwei |last2=Wieser |first2=Andreas |last3=Zhang |first3=Jiang |last4=Liss |first4=Ingrid |last5=Markwardt |first5=Daniel |last6=Hornung |first6=Roman |last7=Neumann-Cip |first7=Anna C. |last8=Mayerle |first8=Julia |last9=Gerbes |first9=Alexander |last10=Steib |first10=Christian J. |date=February 2020 |title=Patients with cirrhosis and SBP: Increase in multidrug-resistant organisms and complications |url=https://pubmed.ncbi.nlm.nih.gov/31886517/ |journal=European Journal of Clinical Investigation |volume=50 |issue=2 |pages=e13198 |doi=10.1111/eci.13198 |issn=1365-2362 |pmid=31886517}}

There are complications associated with SBP such as:

• Renal failure
• Sepsis
• Liver failure/insufficiency
• Tense ascites
• Bleeding after paracentesis
• Bowel perforation after paracentesis
• Spontaneous fungal peritonitis.

Patients with ascites underwent routine paracentesis; the incidence of active SBP ranged from 10% to 27% at the time of hospital admission.{{cite journal | author = Runyon BA | title = Spontaneous bacterial peritonitis: an explosion of information | journal = Hepatology | volume = 8 | issue = 1 | pages = 171–5 | year = 1988 | pmid = 3338704 | doi = 10.1002/hep.1840080131| s2cid = 46406014 | doi-access = free }}

SBP was first described in 1964 by Harold O. Conn.{{cite journal |author=CONN HO |title=Spontaneous peritonitis and bacteremia in Laennec's cirrhosis caused by enteric organisms. A relatively common but rarely recognized syndrome |journal=Ann. Intern. Med. |volume=60 |issue= 4|pages=568–80 |date=April 1964 |pmid=14138877 |doi= 10.7326/0003-4819-60-4-568}}

{{Reflist}}

{{Medical resources

| ICD10 =

| ICD9 = {{ICD9|567.23}}

| eMedicineSubj = emerg

| eMedicineTopic = 882

}}

{{Gastroenterology}}

{{DEFAULTSORT:Spontaneous Bacterial Peritonitis}}

Category:Peritoneum disorders