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.

Prognosis

Mortality from SBP has remained unchanged in recent times^[39] and after reviewing records of 350 patients with SBP admitted to Maryland Hospitals during a 10-year period, SBP was found to be the second leading cause of bacterial-related death in hospitalised patients with a mortality rate of 33%.^[96] Survivors of SBP have a poor prognosis as well. After an initial diagnosis of SBP, 1-month, 6-month and 1-year mortality rates are 33%, 50% and 58% respectively.^[97]

Renal injury develops in 30–40% of patients with SBP and is the best biochemical predictor for mortality.^[98,99] Child–Pugh and MELD scores have also been found to be reliable measures for outcome in these patients.^[39,99]

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Table 1. SBP and other varieties of ascitic fluid infection
Classification	Ascitic fluid analysis	Clinical pearls
Variants of SBP
SBP (culture-positive)	PMNs ≥250 cells/mm³	Patients with cirrhosis and ascites in the presence or absence of symptoms and signs
SBP (culture-positive)	Positive culture
CNNA (culture-negative neutrocytic ascites; culture-negative SBP)	PMNs ≥250 cells/mm³	Poor culture technique, prior antibiotics or low opsonic activity in ascitic fluid. Commonly encountered phenotype and requires antibiotic therapy
	Negative culture
Monomicrobial bacterascites	PMNs <250 cells/mm³	Ascitic fluid infection which may resolve spontaneously or progress to SBP. Similar mortality to SBP and should be treated the same
Monomicrobial bacterascites	Positive culture
Polymicrobial bacterascites	PMNs <250 cells/mm³	Needle perforation
Polymicrobial bacterascites	Positive culture	Needle perforation
Secondary peritonitis	PMNs ≥250 cells/mm³	Intraperitoneal source of infection, e.g. diverticulitis
Secondary peritonitis	Positive culture	Intraperitoneal source of infection, e.g. diverticulitis

Table 2. Microorganisms ( N = 1333) isolated from ascitic fluid in patients with SBP since 1998
Microorganisms	N	Total (%)
Gram-negative bacteria
All Gram-negative bacteria	732	55
Gram-negative bacilli	706	53
E. coli	435	33
Klebsiella	112	8
Other enterobacteriaceae	34	3
Pseudomonas	17	1
Other Gram-negative bacilli	86	6
Anaerobes	27	2
Gram-positive bacteria
All Gram-positive bacteria	575	43
Gram-positive cocci	537	40
Streptococcus spp.	198	15
S. pneumoniae	44	3
Staphylococcus spp.	179	13
S. aureus	70	5
Enterococcus spp.	124	9
Other Gram-positive cocci	43	3
Gram-positive bacilli	23	2
Other	26	2

Spp., species. Other includes fungi, undisclosed spp. Other Gram-negative bacilli include Acinetobacter and Aeromonas. Other enterobacteriaceae includes Enterobacter,Serratia, undisclosed spp. Other Gram-positive cocci include cutaneous flora, undisclosed spp. Other Gram-positive bacilli include Listeria monocytogenes,Bacillus spp., undisclosed spp.
The values in bold add up to 100%.
Sources: Yakar 2010²⁶, Piroth 2009²⁶, Ariza 2012¹⁵¹, Kim 2010¹⁵⁵, Kamani 2008¹⁵², Cheong 2009¹⁵³, Cholongitas 2005¹⁵⁴, Novovic 2012²⁴, Fernandez 2007.⁴⁷

Table 3. Clinical setting of SBP, related definitions and commentary
Health care-associated (HCA) SBP	Diagnosis within 48 h of hospital admission in patients with any prior 90-day health care contact (e.g. hospitalisation, nursing home, dialysis centres or other health care setting).
Nosocomial SBP	Diagnosis after 48 h of hospital admission.
Community acquired (CA) SBP	Diagnosis within 48 h of hospital admission without any prior 90-day health care contact.
Multi-drug resistant SBP	Increasingly encountered because of prior antibiotic exposure. Treat accordingly and prescribe sensitive antibiotics for prophylaxis based on culture sensitivities. Many antibiotics penetrate ascitic fluid equally well. (Gerding Ann Int Med 1977) If TS and FQ resistance, second-generation cephalosporins, e.g. Cefazolin are an option if sensitive.
Recurrent SBP	Portends greater risk of death compared to initial episode of SBP. Provide antibiotic prophylaxis.

TS, trimethoprim–sulfamethoxazole; FQ, fluoroquinolone.

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