Synopsis
Diagnose spontaneous bacterial peritonitis promptly in cirrhosis with ascites, treat before deterioration, prevent renal failure and distinguish a surgically treatable secondary peritonitis.
- Spontaneous bacterial peritonitis is infected ascitic fluid without a surgically treatable intra-abdominal source.
- Perform diagnostic paracentesis promptly for admitted patients with cirrhosis and ascites, especially with pain, fever, encephalopathy, bleeding or renal deterioration.
- An ascitic neutrophil count of at least 250 cells/mm³ supports treatment even when culture is negative.
- Inoculate ascitic fluid into aerobic and anaerobic blood-culture bottles at the bedside to improve microbiological yield.
- Start locally appropriate intravenous antibiotics after sampling; cefotaxime 2 g every eight hours is an established option where susceptibility supports it.
- Consider intravenous human albumin solution at 1.5 g/kg within six hours and 1 g/kg on day three when creatinine is increased or rising.
- Reassess at about 48 hours when response is uncertain; a poor neutrophil fall or polymicrobial result should trigger urgent secondary-source evaluation.
- After recovery, arrange hepatology review, secondary prophylaxis assessment and liver-transplant consideration where appropriate.
Key red flags
Any hospital admission with cirrhosis and ascites requires prompt consideration of diagnostic paracentesis.
Hypotension, rising creatinine, oliguria or lactate indicates severe infection and circulatory dysfunction.
New encephalopathy, ileus or unexplained decompensation may be the only sign of spontaneous bacterial peritonitis.
Marked focal tenderness, free air, polymicrobial culture or poor response suggests secondary peritonitis requiring imaging and surgery.
Gastrointestinal bleeding increases bacterial infection risk and requires the separate cirrhosis bleeding prophylaxis pathway.
New confusion, worsening ascites, renal dysfunction, hypotension, ileus or reduced intake may represent infection even without fever or marked abdominal tenderness.
Diffuse discomfort, tenderness, fever and vomiting support peritonitis, but examination can be deceptively mild in advanced cirrhosis.
Gastrointestinal bleeding, previous spontaneous bacterial peritonitis, low ascitic protein, severe liver failure and recent healthcare exposure increase infection probability or resistance risk.
Focal peritonism, very high neutrophils, polymicrobial culture, free gas, high ascitic protein or failure to respond should prompt urgent anatomical investigation.
Investigation priorities
Establish the neutrophil count before antibiotics and identify fluid features suggesting another source.
Management branches
A patient with cirrhosis and ascites is admitted or develops possible infection or decompensation.
- Perform focused ABCDE assessment, take blood cultures and arrange diagnostic paracentesis as early as possible without awaiting routine correction of INR or platelets.
- Send cell count and differential urgently and inoculate ascites into aerobic and anaerobic blood-culture bottles at the bedside.
- Start locally recommended intravenous treatment immediately after sampling when spontaneous bacterial peritonitis is suspected; do not wait for culture.
- Review diuretics, nephrotoxic medicines, fluid status, gastrointestinal bleeding and the need for higher-level monitoring with hepatology.