Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis

Bruce A Runyon, MD
Section Editor
Keith D Lindor, MD
Deputy Editor
Kristen M Robson, MD, MBA, FACG


Spontaneous bacterial peritonitis (SBP) is defined as an ascitic fluid infection without an evident intra-abdominal surgically treatable source [1]. The presence of SBP, which almost always occurs in patients with cirrhosis and ascites, is suspected because of signs and symptoms such as fever, abdominal pain, or altered mental status (table 1). (See "Spontaneous bacterial peritonitis in adults: Clinical manifestations".)

The diagnosis is established by a positive ascitic fluid bacterial culture and an ascitic fluid absolute polymorphonuclear leukocyte count ≥250 cells/mm3. Patients with SBP should be started on empiric, broad-spectrum antibiotics immediately after peritoneal fluid is obtained. When culture results are available, antibiotic coverage can be tailored to cover the specific organisms identified. (See "Spontaneous bacterial peritonitis in adults: Diagnosis".)

This topic will review the treatment and prophylaxis of SBP. The performance of paracentesis, the pathogenesis, clinical manifestations, and diagnosis of SBP, and the general evaluation of adults with ascites are discussed elsewhere. (See "Diagnostic and therapeutic abdominal paracentesis" and "Pathogenesis of spontaneous bacterial peritonitis" and "Spontaneous bacterial peritonitis in adults: Clinical manifestations" and "Spontaneous bacterial peritonitis variants" and "Spontaneous bacterial peritonitis in adults: Diagnosis" and "Evaluation of adults with ascites".)

In 2013, the American Association for the Study of Liver Diseases updated its guideline on the management of adult patients with ascites due to cirrhosis (table 2) [2,3]. The discussion that follows is consistent with that guideline.


In patients with suspected spontaneous bacterial peritonitis (SBP), empiric therapy should be initiated as soon as possible to maximize the patient's chance of survival (algorithm 1 and table 2) [2,3]. However, antibiotics should not be given until ascitic fluid has been obtained for culture. Most cases of SBP are due to gut bacteria such as Escherichia coli and Klebsiella, though streptococcal and staphylococcal infections can also occur (table 3). As a result, broad-spectrum therapy is warranted until the results of susceptibility testing are available. We prefer cefotaxime 2 g intravenously every eight hours because it has been shown to produce excellent ascitic fluid levels. In addition to antibiotic therapy, patients with SBP who are taking a nonselective beta blocker should have the medication discontinued. (See "Spontaneous bacterial peritonitis in adults: Diagnosis", section on 'Obtaining ascitic fluid'.)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jan 04, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Such J, Runyon BA. Spontaneous bacterial peritonitis. Clin Infect Dis 1998; 27:669.
  2. http://www.aasld.org/practiceguidelines/Documents/ascitesupdate2013.pdf (Accessed on April 23, 2013).
  3. Runyon BA, AASLD. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology 2013; 57:1651.
  4. Mandorfer M, Bota S, Schwabl P, et al. Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology 2014; 146:1680.
  5. McHutchison JG, Runyon BA. Spontaneous bacterial peritonitis. In: Gastrointestinal and Hepatic Infections, Surawicz CM, Owen RL (Eds), WB Saunders, Philadelphia 1994. p.455.
  6. Runyon BA. Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. Hepatology 1990; 12:710.
  7. Pelletier G, Lesur G, Ink O, et al. Asymptomatic bacterascites: is it spontaneous bacterial peritonitis? Hepatology 1991; 14:112.
  8. Antillon MR, Runyon BA. Effect of marked peripheral leukocytosis on the leukocyte count in ascites. Arch Intern Med 1991; 151:509.
  9. Soares-Weiser K, Paul M, Brezis M, Leibovici L. Evidence based case report. Antibiotic treatment for spontaneous bacterial peritonitis. BMJ 2002; 324:100.
  10. Chavez-Tapia NC, Soares-Weiser K, Brezis M, Leibovici L. Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. Cochrane Database Syst Rev 2009; :CD002232.
  11. Rimola A, Salmerón JM, Clemente G, et al. Two different dosages of cefotaxime in the treatment of spontaneous bacterial peritonitis in cirrhosis: results of a prospective, randomized, multicenter study. Hepatology 1995; 21:674.
  12. Chen TA, Lo GH, Lai KH, Lin WJ. Single daily amikacin versus cefotaxime in the short-course treatment of spontaneous bacterial peritonitis in cirrhotics. World J Gastroenterol 2005; 11:6823.
  13. França A, Giordano HM, Sevá-Pereira T, Soares EC. Five days of ceftriaxone to treat spontaneous bacterial peritonitis in cirrhotic patients. J Gastroenterol 2002; 37:119.
  14. Dalmau D, Layrargues GP, Fenyves D, et al. Cefotaxime, desacetyl-cefotaxime, and bactericidal activity in spontaneous bacterial peritonitis. J Infect Dis 1999; 180:1597.
  15. Rastegar LA, Umrani G, Dehbashi N, Malec F. Evaluation of the therapeutic effect of pefloxacin in comparison with ampicillin and gentamicin in cirrhotic patients with spontaneous bacterial peritonitis. Hepatogastroenterology 1998; 45:783.
  16. Felisart J, Rimola A, Arroyo V, et al. Cefotaxime is more effective than is ampicillin-tobramycin in cirrhotics with severe infections. Hepatology 1985; 5:457.
  17. Fernández J, Ruiz del Arbol L, Gómez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology 2006; 131:1049.
  18. Mazer L, Tapper EB, Piatkowski G, Lai M. The need for antibiotic stewardship and treatment standardization in the care of cirrhotic patients with spontaneous bacterial peritonitis - a retrospective cohort study examining the effect of ceftriaxone dosing. F1000Res 2014; 3:57.
  19. Runyon BA, Akriviadis EA, Sattler FR, Cohen J. Ascitic fluid and serum cefotaxime and desacetyl cefotaxime levels in patients treated for bacterial peritonitis. Dig Dis Sci 1991; 36:1782.
  20. Llovet JM, Rodríguez-Iglesias P, Moitinho E, et al. Spontaneous bacterial peritonitis in patients with cirrhosis undergoing selective intestinal decontamination. A retrospective study of 229 spontaneous bacterial peritonitis episodes. J Hepatol 1997; 26:88.
  21. Cabrera J, Arroyo V, Ballesta AM, et al. Aminoglycoside nephrotoxicity in cirrhosis. Value of urinary beta 2-microglobulin to discriminate functional renal failure from acute tubular damage. Gastroenterology 1982; 82:97.
  22. Navasa M, Follo A, Llovet JM, et al. Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis. Gastroenterology 1996; 111:1011.
  23. Terg R, Cobas S, Fassio E, et al. Oral ciprofloxacin after a short course of intravenous ciprofloxacin in the treatment of spontaneous bacterial peritonitis: results of a multicenter, randomized study. J Hepatol 2000; 33:564.
  24. Fernández J, Acevedo J, Castro M, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology 2012; 55:1551.
  25. Ariza X, Castellote J, Lora-Tamayo J, et al. Risk factors for resistance to ceftriaxone and its impact on mortality in community, healthcare and nosocomial spontaneous bacterial peritonitis. J Hepatol 2012; 56:825.
  26. Runyon BA, McHutchison JG, Antillon MR, et al. Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients. Gastroenterology 1991; 100:1737.
  27. Follo A, Llovet JM, Navasa M, et al. Renal impairment after spontaneous bacterial peritonitis in cirrhosis: incidence, clinical course, predictive factors and prognosis. Hepatology 1994; 20:1495.
  28. Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999; 341:403.
  29. Sigal SH, Stanca CM, Fernandez J, et al. Restricted use of albumin for spontaneous bacterial peritonitis. Gut 2007; 56:597.
  30. Salerno F, Navickis RJ, Wilkes MM. Albumin infusion improves outcomes of patients with spontaneous bacterial peritonitis: a meta-analysis of randomized trials. Clin Gastroenterol Hepatol 2013; 11:123.
  31. Runyon BA, Hoefs JC, Canawati HN. Polymicrobial bacterascites. A unique entity in the spectrum of infected ascitic fluid. Arch Intern Med 1986; 146:2173.
  32. Tandon P, Garcia-Tsao G. Renal dysfunction is the most important independent predictor of mortality in cirrhotic patients with spontaneous bacterial peritonitis. Clin Gastroenterol Hepatol 2011; 9:260.
  33. Karvellas CJ, Abraldes JG, Arabi YM, et al. Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis-associated septic shock: a retrospective cohort study. Aliment Pharmacol Ther 2015; 41:747.
  34. Titó L, Rimola A, Ginès P, et al. Recurrence of spontaneous bacterial peritonitis in cirrhosis: frequency and predictive factors. Hepatology 1988; 8:27.
  35. Andreu M, Sola R, Sitges-Serra A, et al. Risk factors for spontaneous bacterial peritonitis in cirrhotic patients with ascites. Gastroenterology 1993; 104:1133.
  36. Rasaratnam B, Kaye D, Jennings G, et al. The effect of selective intestinal decontamination on the hyperdynamic circulatory state in cirrhosis. A randomized trial. Ann Intern Med 2003; 139:186.
  37. Runyon BA, Antillon MR, Montano AA. Effect of diuresis versus therapeutic paracentesis on ascitic fluid opsonic activity and serum complement. Gastroenterology 1989; 97:158.
  38. Goel GA, Deshpande A, Lopez R, et al. Increased rate of spontaneous bacterial peritonitis among cirrhotic patients receiving pharmacologic acid suppression. Clin Gastroenterol Hepatol 2012; 10:422.
  39. Deshpande A, Pasupuleti V, Thota P, et al. Acid-suppressive therapy is associated with spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis. J Gastroenterol Hepatol 2013; 28:235.
  40. Terg R, Casciato P, Garbe C, et al. Proton pump inhibitor therapy does not increase the incidence of spontaneous bacterial peritonitis in cirrhosis: a multicenter prospective study. J Hepatol 2015; 62:1056.
  41. Ge PS, Runyon BA. Preventing future infections in cirrhosis: a battle cry for stewardship. Clin Gastroenterol Hepatol 2015; 13:760.
  42. Runyon BA. Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis. Gastroenterology 1986; 91:1343.
  43. Soriano G, Guarner C, Teixidó M, et al. Selective intestinal decontamination prevents spontaneous bacterial peritonitis. Gastroenterology 1991; 100:477.
  44. Ginés P, Rimola A, Planas R, et al. Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: results of a double-blind, placebo-controlled trial. Hepatology 1990; 12:716.
  45. Soares-Weiser K, Brezis M, Tur-Kaspa R, et al. Antibiotic prophylaxis of bacterial infections in cirrhotic inpatients: a meta-analysis of randomized controlled trials. Scand J Gastroenterol 2003; 38:193.
  46. Grangé JD, Roulot D, Pelletier G, et al. Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites: a double-blind randomized trial. J Hepatol 1998; 29:430.
  47. Soriano G, Guarner C, Tomás A, et al. Norfloxacin prevents bacterial infection in cirrhotics with gastrointestinal hemorrhage. Gastroenterology 1992; 103:1267.
  48. Terg R, Fassio E, Guevara M, et al. Ciprofloxacin in primary prophylaxis of spontaneous bacterial peritonitis: a randomized, placebo-controlled study. J Hepatol 2008; 48:774.
  49. Fernández J, Navasa M, Planas R, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology 2007; 133:818.
  50. Runyon BA, Borzio M, Young S, et al. Effect of selective bowel decontamination with norfloxacin on spontaneous bacterial peritonitis, translocation, and survival in an animal model of cirrhosis. Hepatology 1995; 21:1719.
  51. Ortiz J, Vila MC, Soriano G, et al. Infections caused by Escherichia coli resistant to norfloxacin in hospitalized cirrhotic patients. Hepatology 1999; 29:1064.
  52. Wade JJ, Rolando N, Hayllar K, et al. Bacterial and fungal infections after liver transplantation: an analysis of 284 patients. Hepatology 1995; 21:1328.
  53. Tandon P, Delisle A, Topal JE, Garcia-Tsao G. High prevalence of antibiotic-resistant bacterial infections among patients with cirrhosis at a US liver center. Clin Gastroenterol Hepatol 2012; 10:1291.
  54. Rolando N, Gimson A, Philpott-Howard J, et al. Infectious sequelae after endoscopic sclerotherapy of oesophageal varices: role of antibiotic prophylaxis. J Hepatol 1993; 18:290.
  55. Lo GH, Lai KH, Shen MT, Chang CF. A comparison of the incidence of transient bacteremia and infectious sequelae after sclerotherapy and rubber band ligation of bleeding esophageal varices. Gastrointest Endosc 1994; 40:675.
  56. Novella M, Solà R, Soriano G, et al. Continuous versus inpatient prophylaxis of the first episode of spontaneous bacterial peritonitis with norfloxacin. Hepatology 1997; 25:532.
  57. Rolachon A, Cordier L, Bacq Y, et al. Ciprofloxacin and long-term prevention of spontaneous bacterial peritonitis: results of a prospective controlled trial. Hepatology 1995; 22:1171.
  58. Singh N, Gayowski T, Yu VL, Wagener MM. Trimethoprim-sulfamethoxazole for the prevention of spontaneous bacterial peritonitis in cirrhosis: a randomized trial. Ann Intern Med 1995; 122:595.
  59. Terg R, Llano K, Cobas SM, et al. Effects of oral ciprofloxacin on aerobic gram-negative fecal flora in patients with cirrhosis: results of short- and long-term administration, with daily and weekly dosages. J Hepatol 1998; 29:437.
  60. Saab S, Hernandez JC, Chi AC, Tong MJ. Oral antibiotic prophylaxis reduces spontaneous bacterial peritonitis occurrence and improves short-term survival in cirrhosis: a meta-analysis. Am J Gastroenterol 2009; 104:993.
  61. Loomba R, Wesley R, Bain A, et al. Role of fluoroquinolones in the primary prophylaxis of spontaneous bacterial peritonitis: meta-analysis. Clin Gastroenterol Hepatol 2009; 7:487.
  62. Inadomi J, Sonnenberg A. Cost-analysis of prophylactic antibiotics in spontaneous bacterial peritonitis. Gastroenterology 1997; 113:1289.