Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Perform diagnostic paracentesis in any hospitalized cirrhotic with ascites.
- If PMN ≥250/µL or strong suspicion → start IV antibiotics and give albumin per protocol.
- Assess for HRS; adjust diuretics and manage precipitating factors; start secondary prophylaxis at discharge.
Clinical Synopsis & Reasoning
In cirrhosis with ascites, perform immediate diagnostic paracentesis. Treat SBP when PMN ≥250/µL with IV third-generation cephalosporin and give IV albumin (day 1: 1.5 g/kg; day 3: 1.0 g/kg) to prevent renal failure. Start lifelong prophylaxis after an episode.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Paracentesis (cell count, culture in blood-culture bottles) | Diagnosis | PMN ≥250/µL | Do not delay antibiotics |
| Renal function, bilirubin, INR | Prognosis | HRS risk | Guide albumin |
| Blood/urine cultures if sepsis suspected | Etiology | Concomitant infections | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| SBP with organ dysfunction (HRS, encephalopathy) | High mortality | ICU; early albumin; consider terlipressin for HRS |
| Nosocomial or resistant organisms suspected | Treatment failure risk | Broaden antibiotics per local ecology |
| GI bleeding within past week | Infection risk | Empiric prophylaxis and close monitoring |
| Recurrent SBP | Prevention needed | Start long-term prophylaxis |
| Poor outpatient reliability | Safety | Observation admission |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Ceftriaxone 1–2 g IV daily (or cefotaxime) | Antibiotic | Hours | Empiric coverage | Adjust per cultures/local resistance |
| Albumin 1.5 g/kg (day 1) and 1.0 g/kg (day 3) | Colloid | Hours-days | Prevents HRS | Weight-based dosing |
| Norfloxacin/trimethoprim-sulfamethoxazole (secondary prophylaxis) | Antimicrobial | Days | Prevent recurrence | Resistance concerns |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- AASLD practice guidance on SBP — Link