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.
Key red flags
Any hospital admission with cirrhosis and ascites requires prompt consideration of diagnostic paracentesis.
New confusion, worsening ascites, renal dysfunction, hypotension, ileus or reduced intake may represent infection even without fever or marked abdominal tenderness.
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.
Key medicines
CefotaximeGive 2 g intravenously every eight hours for about five days when local susceptibility and the clinical setting support this regimen.
Human albumin solutionGive 1.5 g/kg intravenously within six hours of diagnosis and 1 g/kg intravenously on day three when creatinine is increased or rising.