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 paracentesis before antibiotics when safe; diagnose with PMN ≥250.
- Start cefotaxime/ceftriaxone and albumin; manage complications; stop diuretics if AKI.
- Plan secondary prophylaxis; evaluate for transplant; vaccination and counseling.
Clinical Synopsis & Reasoning
In any cirrhotic with ascites and abdominal pain or encephalopathy, perform diagnostic paracentesis; PMN ≥250 cells/mm³ confirms SBP. Start cefotaxime or ceftriaxone promptly and give albumin on day 1 and 3 to prevent renal failure; begin long-term prophylaxis after recovery when indicated.
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 |
|---|
| Ascitic fluid cell count, albumin, culture in blood culture bottles | Diagnosis | PMN ≥250, SAAG, organism ID | Essential first step |
| Renal function and bilirubin | Prognosis | AKI risk guides albumin dosing | — |
| Ultrasound for ascites and complications | Adjunct | Guide tap and r/o loculations | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Sepsis, hypotension, or AKI | High mortality | ICU; albumin for renal protection |
| SBP recurrence or MDR organisms | Treatment failure risk | ID consult; adjust antibiotics |
| GI bleeding | Infection risk ↑ | Prophylactic antibiotics |
| Severe hyponatremia/hepatic encephalopathy | Decompensation | Close monitoring |
| Transplant candidate | Prognosis | Notify transplant team |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Cefotaxime 2 g IV q8h or Ceftriaxone 2 g IV daily | Antibiotics | Hours | First-line empiric therapy | Adjust to culture |
| Albumin 1.5 g/kg day 1 + 1.0 g/kg day 3 | Renal protection | Days | Prevents HRS/AKI | Dose by weight |
| Norfloxacin/TMP‑SMX for secondary prophylaxis | Prevention | Days | Reduce recurrence | Avoid with resistance issues |
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 ascites/SBP guidance — Link