Spontaneous Bacterial Peritonitis

  • Ajay M. OhriEmail author
  • Indhu M. Subramanian


Spontaneous bacterial peritonitis (SBP) is a frequent and serious complication of ascites in the presence of advanced cirrhosis. Although SBP can be considered in other conditions associated with the presence of chronic ascites, SBP is most commonly associated with ascites from cirrhosis and its presence correlates with more advanced liver disease. SBP is defined as an ascitic fluid infection in the absence of a surgical etiology. Delay in recognition and appropriate treatment of peritoneal infections such as SBP can lead to sepsis and death. Symptoms include fever, abdominal pain, nausea and altered mental status although patients can be asymptomatic. Translocation of enteric bacteria from the gut into the peritoneal cavity accounts for the majority of SBP cases; however, other organisms, (fungal, mycobacteria, and more resistant nosocomial bacteria), can also be pathogenic and lead to peritonitis. The clinical diagnosis of SBP is suspected by the presence of ascites and compatible symptoms and is confirmed by ascitic fluid analysis showing elevated polymorphonuclear cells and a positive microbiologic culture. It is imperative to rule out secondary causes of peritonitis. Treatment primarily includes antibiotics and adjunctive albumin therapy in appropriate patients. Prophylaxis is a cornerstone of therapy for patients meeting criteria. Early identification and management of SBP has transformed this condition from one carrying a high mortality rate to a fairly well-managed and treated complication of chronic ascites in cirrhotic patients.


Spontaneous bacterial peritonitis (SBP) Ascites Complicated cirrhosis SBP prophylaxis Albumin for SBP Fungal bacterial peritonitis Multi-resistant bacterial peritonitis Polymicrobial bacterascites Secondary bacterial peritonitis Abdominal compartment syndrome 


  1. 1.
    Runyon BA. Management of adult patient with ascites due to cirrhosis: update 2012. The American Association for the Study of Liver Diseases. AASLD Practice Guideline 2013; 1–87.Google Scholar
  2. 2.
    Orman ES, Hayashi PH, Bataller R, Barritt AS. Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites. Clin Gastroenterol Hepatol. 2014;12(3):496–503.CrossRefPubMedGoogle Scholar
  3. 3.
    Kim JJ, Tsukamoto MM, Mathur AK, Ghomri YM, Hou LA, Sheibani S, et al. Delayed paracentesis is associated with increased in-hospital mortality in patients with SBP. Am J Gastroenterol. 2014;1D9(9):1436–42.CrossRefGoogle Scholar
  4. 4.
    Such J, Runyon BA. Spontaneous bacterial peritonitis. Clin Infect Dis. 1998;27(4):669–74.CrossRefPubMedGoogle Scholar
  5. 5.
    Deshpande A, Pasupuleti V, Thota P, Pant C, Mapara S, Hassan S, et al. Acid-suppressive therapy is associated with spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis. J Gastroenterol Hepatol. 2013;28(2):235–42.CrossRefPubMedGoogle Scholar
  6. 6.
    Sundaram V, Manne V, Al-Osaimi AM. Ascites and SBP: recommendations from two United States centers. Saudi J Gastroenterol. 2014;2D(5):279–87. Scholar
  7. 7.
    Akriviadis EA, Runyon BA. Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology. 1990;98(1):127–33.CrossRefPubMedGoogle Scholar
  8. 8.
    Runyon BA, Canawati HN, Akriviadis EA. Optimization of ascitic fluid culture technique. Gastroenterology. 1988;95(5):1351–5.CrossRefPubMedGoogle Scholar
  9. 9.
    Runyon BA. Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. Hepatology. 1990;12(4 pt 1):710–5.CrossRefPubMedGoogle Scholar
  10. 10.
    Pelletier G, Lesur G, Ink O, Hagege H, Attali P, Buffet C, et al. Asymptomatic bacterascites: is it spontaneous bacterial peritonitis? Hepatology. 1991;14(1):112–5.CrossRefPubMedGoogle Scholar
  11. 11.
    Antillon MR, Runyon BA. Effect of marked peripheral leukocytosis on the leukocyte count in ascites. Arch Intern Med. 1991;151(3):509–10.CrossRefPubMedGoogle Scholar
  12. 12.
    Hoefs JC. Increase in ascites white blood cell and protein concentrations during diuresis in patients with chronic liver disease. Hepatology. 1981;1(3):249–54.CrossRefPubMedGoogle Scholar
  13. 13.
    Moore CM, Van Thiel DH. Cirrhotic ascites review: pathophysiology, diagnosis and management. World J Hepatol. 2013;5(5):251–63.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Runyon BA, AASLD. Introduction to the revised American Association for the study of liver diseases practice guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013;57(4):1651–3. Scholar
  15. 15.
    Garcia-Martinez I, Francés R, Zapater P, et al. Use of proton pump inhibitors decrease cellular oxidative burst in patients with decompensated cirrhosis. J Gastroenterol Hepatol. 2015;30:147–54.CrossRefPubMedGoogle Scholar
  16. 16.
    Min YW, Lim KS, Min BH, et al. Proton pump inhibitor use significantly increases the risk of spontaneous bacterial peritonitis in 1965 patients with cirrhosis and ascites: a propensity score matched cohort study. Aliment Pharmacol Ther. 2014;40:695–704.CrossRefPubMedGoogle Scholar
  17. 17.
    Runyon BA, Morrissey RL, Hoefs JC, Wyle FA. Opsonic activity of human ascitic fluid: a potentially important protective mechanism against SBP. Hepatology. 1985;5(4):634–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Konstantakis C, Tselekouni P, Kalafateli M, Triantos C. Vitamin D deficiency in patients with liver cirrhosis. Ann Gastroenterol. 2016;29(3):297–306.PubMedPubMedCentralGoogle Scholar
  19. 19.
    De Mattos AA, Costabeber AM, Lionco LC, Tovo CV. Multi-resistant bacteria in spontaneous bacterial peritonitis: a new step in management? World J Gastroenterol. 2014;20(39):14D79–86. Scholar
  20. 20.
    Bal CK, Bhatia V, Khillan V, Rathor N, Saini D, Daman R, et al. Spontaneous cryptococcal peritonitis with fungemia in patients with decompensated cirrhosis: report of two cases. Indian J Crit Care Med. 2014;18(8):536–9. Scholar
  21. 21.
    Diaz-Fontenla F, Perez- Valderas M, Ibanez-Samaniego L, Gracia-Fernandez CP, Flores-Fernandez V. Spontaneous Listeria monocytogenes bacterial peritonitis. Rev Clin Esp. 2014;214(5):285–6. Scholar
  22. 22.
    Runyon BA, Akriviadis EA, Sattler FR, Cohen J. Ascitic fluid and serum cefotaxime and desacetyl cefotaxime levels in patients treated for bacterial peritonitis. Dig Dis Sci. 1991;36(12):1782–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Fernandez J, Ruiz del Arbol L, Gomez C, Durandez R, Serradilla R, Guarner C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006;131(4):1049–56; quiz 1285CrossRefPubMedGoogle Scholar
  24. 24.
    Salerno F, Navickis RJ, Wilkes MM. Albumin infusion improves outcomes of patients with spontaneous bacterial peritonitis: a meta-analysis of randomized trials. Clin Gastroenterol Hepatol. 2013;11(2):123–130.e1.CrossRefPubMedGoogle Scholar
  25. 25.
    Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del-arbol L, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1990;34(6):403–9.CrossRefGoogle Scholar
  26. 26.
    Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M, et al. Nonselective B-blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology. 2014;146(7):1680–1690.e1.CrossRefPubMedGoogle Scholar
  27. 27.
    Runyon BA, Anillon MR, Montano AA. Effect of diuresis versus therapeutic paracentesis on ascitic fluid opsonic activity and serum complement. Gastroenterology. 1989;97(1):158–62.CrossRefPubMedGoogle Scholar
  28. 28.
    Fernández J, Navasa M, Planas R, Montoliu S, Monfort D, Soriano G, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology. 2007;133(3):818–24.CrossRefPubMedGoogle Scholar
  29. 29.
    Terg R, Fassio E, Guevara M, Cartier M, Longo C, Lucero R, et al. Ciprofloxacin in primary prophylaxis of spontaneous bacterial peritonitis: a randomized, placebo-controlled study. J Hepatol. 2008;48(5):774–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Grangé JD, Roulot D, Pelletier G, Pariente EA, Denis J, Ink O, et al. Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites: a double-blind randomized trial. J Hepatol. 1998;29(3):430–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Soares-Weiser K, Brezis M, Tur-Kaspa R, Paul M, Yahav J, Leibovici L. Antibiotic prophylaxis of bacterial infections in cirrhotic inpatients: a meta-analysis of randomized controlled trials. Scand J Gastroenterol. 2003;38(2):193–200.CrossRefPubMedGoogle Scholar
  32. 32.
    Runyon BA, McHutchison JG, Antillon MR, Akriviadis EA, Montano AA. Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients. Gastroenterology. 1991;100(6):1737–42.CrossRefPubMedGoogle Scholar
  33. 33.
    Parsi MA, Saadeh SN, Zein NN, et al. Ascitic fluid lactoferrin for diagnosis of spontaneous bacterial peritonitis. Gastroenterology. 2008;135:803–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Weil D, Heurgue-Berlot A, Monnet E, Chassagne S, Cervoni JP, Feron T, Grandvallet C, Muel E, Bronowicki JP, Thiefin G, Di Martino V, Bardonnet K, Thévenot T. Accuracy of calprotectin using the quantum blue reader for the diagnosis of spontaneous bacterial peritonitis in liver cirrhosis. Hepatol Res. 2018;49:72–81. Scholar
  35. 35.
    Anty R, Tonohouan M, Ferrari-Panaia P, et al. Low levels of 25-hydroxy vitamin D are independently associated with the risk of bacterial infection in cirrhotic patients. Clin Transl Gastroenterol. 2014;5(5):e56. Scholar
  36. 36.
    Elfert A, Abo Ali L, Soliman S, Ibrahim S, Abd-Elsalam S. Randomized-controlled trial of rifaximin versus norfloxacin for secondary prophylaxis of spontaneous bacterial peritonitis. Eur J Gastroenterol Hepatol. 2016;28:1450–4.CrossRefPubMedGoogle Scholar
  37. 37.
    Kamal F, Khan MA, Khan Z, Cholankeril G, Hammad TA, Lee WM, Ahmed A, Waters B, Howden CW, Nair S, Satapathy SK. Rifaximin for the prevention of spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol. 2017;29(10):1109–17.CrossRefPubMedGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Internal MedicineHighland Hospital, Alameda Health SystemOaklandUSA
  2. 2.Pulmonary and Critical Care Faculty, Department of Internal MedicineHighland Hospital, Alameda Health SystemOaklandUSA

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