Diagnosis of SBP:

1. PMNs >250 cells/mm3
2. Positive bacterial cultures
3. Absence of secondary causes (i.e. bowel perforation)

Secondary Peritonitis:

1. PMNs >250 cells/mm3
2. Positive bacterial cultures (typically poly microbial)
3. Surgically treatable intra-abdominal source of infection

Remember it is important to distinguish SBP from secondary peritonitis for two main reasons:

• Mortality of secondary bacterial peritonitis is approximately 100% without surgical intervention
• Mortality of SBP approaches approximately 80% if patient undergoes an unnecessary exploratory laparotomy

Common pathogens in SBP:

• E. coli (43%)
• Strep species (28%)
• Klebsiella pneumonia (11%)

SAAG – serum ascites albumin gradient (subtract the ascitic albumin from the serum level)

• If >1.1 g/dL patient has portal hypertension (97% ACCURATE)

Reasons for Albumin Repletion:

1. Prevention of post-paracentesis circulatory dysfunction (PPCD)
   • >4L give 6-8 g/L for each L removed
2. Prevention of renal impairment in cirrhotic patients with SBP
   • Give 1.5 g/kg DAY 1
   • Give 1.0 g/kg DAY 3
3. Diagnosis/treatment of HRS
   • Give 1.0 g/kg on DAYS 1 AND 2 (maximum of 100 g each)
   • If renal function improves, suggestive of pre-renal hypovolemia; if renal function worsens, suggestive of HRS.