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Spontaneous bacterial peritonitis variants

Bruce A Runyon, MD
Section Editor
Keith D Lindor, MD
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF


Spontaneous bacterial peritonitis (SBP) is defined as an ascitic fluid infection without an evident intraabdominal surgically treatable source; it primarily occurs in patients with advanced cirrhosis [1,2]. The diagnosis is established by a positive ascitic fluid bacterial culture and an elevated ascitic fluid absolute polymorphonuclear leukocyte (PMN) count (≥250 cells/mm3).

When faced with a patient who appears to have spontaneous bacterial peritonitis (SBP), the clinician should at least consider the possibility that the patient might have a surgically treatable source for the infection (eg, a ruptured peptic ulcer) (see "Spontaneous bacterial peritonitis in adults: Diagnosis"). This distinction is crucial because the mortality of secondary bacterial peritonitis in the presence of ascites approaches 100 percent, if treated only with antibiotics with no surgical intervention [1]. Conversely, if a patient with SBP receives an unnecessary exploratory laparotomy, the mortality is approximately 80 percent [3]. With appropriate antibiotic treatment of SBP, infection-related mortality approaches zero [4]. (See "Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis".)

There are three variants of SBP that are also "spontaneous" (ie, there is no surgically treatable source for the infection) (table 1) [5]:

Culture-negative neutrocytic ascites

Monomicrobial non-neutrocytic bacterascites


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Literature review current through: Sep 2016. | This topic last updated: Jul 17, 2014.
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  1. Akriviadis EA, Runyon BA. Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology 1990; 98:127.
  2. Runyon BA, AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology 2009; 49:2087.
  3. Garrison RN, Cryer HM, Howard DA, Polk HC Jr. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg 1984; 199:648.
  4. 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.
  5. Sheer TA, Runyon BA. Spontaneous bacterial peritonitis. Dig Dis 2005; 23:39.
  6. Runyon BA, Hoefs JC. Culture-negative neutrocytic ascites: a variant of spontaneous bacterial peritonitis. Hepatology 1984; 4:1209.
  7. Hillebrand DJ, Runyon BA, Yasmineh WG, Rynders GP. Ascitic fluid adenosine deaminase insensitivity in detecting tuberculous peritonitis in the United States. Hepatology 1996; 24:1408.
  8. Runyon BA, Hoefs JC, Morgan TR. Ascitic fluid analysis in malignancy-related ascites. Hepatology 1988; 8:1104.
  9. Hoefs JC. Increase in ascites white blood cell and protein concentrations during diuresis in patients with chronic liver disease. Hepatology 1981; 1:249.
  10. Runyon BA, Canawati HN, Akriviadis EA. Optimization of ascitic fluid culture technique. Gastroenterology 1988; 95:1351.
  11. McHutchison JG, Runyon BA. Spontaneous bacterial peritonitis. In: Gastrointestinal and Hepatic Infections, Surawicz CM, Owen RL (Eds), WB Saunders, Philadelphia 1994. p.455.
  12. Evans LT, Kim WR, Poterucha JJ, Kamath PS. Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites. Hepatology 2003; 37:897.
  13. Pelletier G, Salmon D, Ink O, et al. Culture-negative neutrocytic ascites: a less severe variant of spontaneous bacterial peritonitis. J Hepatol 1990; 10:327.
  14. Kim SU, Kim DY, Lee CK, et al. Ascitic fluid infection in patients with hepatitis B virus-related liver cirrhosis: culture-negative neutrocytic ascites versus spontaneous bacterial peritonitis. J Gastroenterol Hepatol 2010; 25:122.
  15. Antillon MR, Runyon BA. Effect of marked peripheral leukocytosis on the leukocyte count in ascites. Arch Intern Med 1991; 151:509.
  16. Runyon BA. Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. Hepatology 1990; 12:710.
  17. Pelletier G, Lesur G, Ink O, et al. Asymptomatic bacterascites: is it spontaneous bacterial peritonitis? Hepatology 1991; 14:112.
  18. Runyon BA, Hoefs JC, Canawati HN. Polymicrobial bacterascites. A unique entity in the spectrum of infected ascitic fluid. Arch Intern Med 1986; 146:2173.