Spontaneous Bacterial Peritonitis (SBP) — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Ascitic PMN count
   In a cirrhotic with ascites, the ascitic neutrophil (PMN) count on diagnostic paracentesis? (Cirrhotic ascites with suspected infection (fever, abdominal pain, worsening encephalopathy, deteriorating renal function; may be asymptomatic) → diagnostic paracentesis. Ascitic PMN ≥250/mm3 (0.25×10^9/L) = SBP. Culture-negative neutrocytic ascites (PMN ≥250, culture negative) is treated as SBP. Inoculate ascites into blood-culture bottles at the bedside. SAAG ≥1.1 indicates a portal-hypertension background.)
   • PMN ≥250 (SBP) → SBP → antibiotics + albumin
   • PMN <250 → PMN <250
2. [End] PMN <250
   Not SBP. Culture-positive with PMN <250 (bacterascites): no antibiotics if asymptomatic, repeat paracentesis; treat as SBP if symptomatic (fever/abdominal pain). Watch for secondary peritonitis (very high PMN, polymicrobial, high protein/LDH or low glucose → look for perforation).
3. [End] SBP → antibiotics + albumin
   1) Empiric 3rd-generation cephalosporin — cefotaxime 2 g IV q8h (or ceftriaxone 2 g q24h), ≥5 days, de-escalate by culture; broaden for healthcare-associated/recent beta-lactam exposure per local resistance. 2) Albumin: 1.5 g/kg on day 1 (within 6 h of the first antibiotic) + 1 g/kg on day 3, reducing hepatorenal syndrome and mortality (especially with raised Cr, BUN, bilirubin). 3) After recovery, quinolone (norfloxacin/ciprofloxacin) prophylaxis to prevent recurrence.

Source guidelines & references

• AASLD guideline on ascites, SBP and hepatorenal syndrome in cirrhosis; EASL guideline on decompensated cirrhosis

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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