Question 26

a)    In patients with hepatic cirrhosis and ascites, list three risk factors for developing spontaneous bacterial peritonitis.    (30% marks)
b)    In a patient with suspected spontaneous bacterial peritonitis, explain your approach to antimicrobial therapy.    (40% marks)

c)    List three further management priorities for the management of spontaneous bacterial peritonitis. (30% marks)

[Click here to toggle visibility of the answers]

College answer

Not available.



Risk factors for SBP could include:

  • Child-Pugh Grade C cirrhosis
  • Ascitic fluid protein level less than 10g/L
  • Gastrointestinal bleeding
  • Urinary tract infection
  • Intestinal bacterial overgrowth
  • Invasive devices: central lines, peripheral cannulae, IDCs 
  • Previous SBP episodes


b)  "Explain your approach to antimicrobial therapy" in a patient with "suspected" SBP, they asked. Well, first:

  • "Suspected" SBP needs to be confirmed by ascitic tap microscopy and culture.
  • If microscopy confirms total white cell count of more than 0.5 × 109/L or neutrophil count of more than 0.25 × 109/L, empiric antimicrobial therapy can commence. 
  • Empirical therapy would need to cover:
    • Gram-negatives including
      • E. coli
      • K. pneumoniae
    • Gram-positives including:
      • S. pneumoniae  
      • S. viridans
      • Enterococcus
  • Thus, the following are valid choices:
    • Ceftriaxone, 2g daily
    • Cefotaxime, 2g tds
  • For patients who develop SBP while in hospital, the spectrum of pathogens is broader, and may include cephalosporion-resistant species. For these patients the best option is piperacillin-tazobactam, 4.5g tds.
  • Failure to improve with empirical therapy should prompt thinking about fungal SBP, which is rarer (0-7%) but has a higher mortality (up to 80%!), and would call for an empirical echinocandin (eg. anidulafungin). The trainee could include this in their answer, with the caveat that it is not listed in the empirical antibiotic choices of any of the major guidelines.

c) "Three further management priorities" 

  • Prevent hepatorenal syndrome
    • Albumin infusion (1.5 g/kg at diagnosis and 1g/kg on day 3)
    • Stop diuretics
  • Decrease bacterial overgrowth and translocation:
    • Enteral nutrition
    • Cease proton pump inhibitors (promote decontamination of gastric content), though it is controversial (i.e not all are uniformly agreed that this makes a difference, and most patients with cirrhosis also have varices, so...)
    • Rifaxamine
  • Confirm resolution and prevent recurrence
    • Repeat paracentesis
    • Assess risk factors and commence prophylactic antibiotics if appropriate

These recommendations cannot be found together in any specific guideline, and represent a melange of several publications, not the least of which is the UpToDate article by Runyon and the EASL clinical practice guidelines from 2010.


Such, Jose, and Bruce A. Runyon. "Spontaneous bacterial peritonitis." Clinical infectious diseases (1998): 669-674.

Foris, Lisa A., and Melanie T. Stapleton. "Spontaneous Bacterial Peritonitis." (2017).

Koulaouzidis, Anastasios, Shivaram Bhat, and Athar A. Saeed. "Spontaneous bacterial peritonitis." World Journal of Gastroenterology: WJG 15.9 (2009): 1042.

Runyon, Bruce A. "Chapter 91. Ascites and Spontaneous Bacterial Peritonitis." (2002). Ch. 91; in: 

European Association For The Study Of The Liver. "EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis." Journal of hepatology 53.3 (2010): 397-417.

Shizuma, Toru. "Spontaneous bacterial and fungal peritonitis in patients with liver cirrhosis: A literature review." World journal of hepatology 10.2 (2018): 254.

Fiore, Marco, et al. "Spontaneous peritonitis in critically ill cirrhotic patients: a diagnostic algorithm for clinicians and future perspectives." Therapeutics and Clinical Risk Management (2017): 1409-1414.