Review Article

Spontaneous Bacterial Peritonitis – Bacteriology, Diagnosis, Treatment, Risk Factors and Prevention

J. B. Dever; M. Y. Sheikh


Aliment Pharmacol Ther. 2015;41(11):1116-1131. 

In This Article

Supportive Therapy


Patients with advanced cirrhosis have continued protein catabolism, also referred to as hypermetabolism, and the majority suffer from malnutrition.[138] There are no studies assessing the role of diet in prevention or treatment of SBP; however, malnutrition predisposes to bacterial translocation and SBP as demonstrated in experiments with rats.[139] Simple evidence-based dietary measures should not be overlooked when providing patient recommendations. Referral for dietician consultation is at the discretion of clinicians and will at least imprint the importance of diet in health. Patients with cirrhosis should avoid raw food due to the risk of consuming harmful bacteria, limit dietary sodium intake, aim for 1.2–1.5 g of daily protein intake[140] and generally should consume 4–6 small frequent meals throughout the day including a bedtime carbohydrate-rich snack.[141]


Anaerobic bacteria species such as Lactobacillus and Bifidobacterium are normal inhabitants of the gastrointestinal lumen, are less likely to translocate compared to Gram-negative aerobic bacteria,[142] and have been hypothesised to play a role in the prevention of SBP. In fact, VSL#3 (Lactobacillus spp., Bifidobacterium spp., Streptococcus salivarius spp. and Thermophilus spp.) has been shown to improve hepatic function and decrease liver enzymes in patients with cirrhosis,[143] and Lactobacillus combined with antioxidants (vitamin C and glutamate) have been shown to decrease endotoxemia compared to water lavage in rats with induced cirrhosis.[144] Subsequent studies involving a similar rat model have used Lactobacillus alone, which has succeeded in changing the intestinal milieu of the host but not SBP occurrence.[145,146] The addition of probiotics to a daily norfloxacin regimen did not improve outcomes with regard to primary or secondary SBP prophylaxis nor did it demonstrate a survival benefit in a randomised, double-blind, placebo-controlled trial with 6-month follow-up.[147] The health benefits of probiotic therapy for a variety of gastrointestinal illnesses are well known although no evidence supports their use in the prevention or management of SBP.