Teaching Points:

• Diagnosed with positive ascitic cultures and/or ascitic PMN count >250
• Occurs in the setting of patients having ascites.
  • If patient does not have ascites, VERY unlikely to have SBP.
  • Only few documented cased were noted in children who had SBP without ascites. Not seen in adults.
• Common infectious etiologies include gram negatives (e. coli, klebsiella) but can also include gram positives such as strep
• Clinically presents with abdominal discomfort, distension, fevers, and acute encephalopathy.
• Empiric treatment includes the following:
  • 3rd generation cephalosporin for 5 days
    • cefotaxime
    • ceftriaxone (2g IV q12 for those with normal renal function)
  • Albumin
    • 1.5g/kg on Day 1
    • 1.0g/kg on Day 3
• Important to distinguish between spontaneous bacterial peritonitis and secondary bacterial peritonitis
  • Degree of PMN elevation
  • Presence and risk of surgically treatable infections
• SBP Prophylaxis
  • History of SBP
    • Patients should be on lifelong prophylaxis (fluoroquinolones or Bactrim)
  • Cirrhosis with GI bleed
    • Patients should be on ceftriaxone until bleed is stable, then can transition to flouroquinolone. Total antibiotic treatment of 7 days
  • Ascitic total protein <1g/dl
    • If hospitalized, even for non-cirrhotic complication, patient should receive fluoroquinolone during inpatient stay.
• Albumin Challenges
  • Spontaneous bacterial peritonitis
    • Very high risk for developing HRS
    • 1.5g/kg on Day 1, 1.0g/kg on Day 3
  • AKI – distinguish between HRS vs pre-renal hypovolemia
    • Albumin fluid challenge on Days 1 and 2
    • 1g/kg on both days; max dose of 100g
    • If renal function improves, suggestive of pre-renal hypovolemia. If renal function worsens, suggestive of HRS
  • Large Volume Paracentesis (>4L)
    • Give 6-8 grams albumin per liter removed