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Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis

EASL Recommendations 

1.A diagnostic paracentesis should be carried out in all patients with cirrhosis and ascites at hospital admission to rule out SBP. A diagnostic paracentesis should also, be performed in patients with gastrointestinal bleeding, shock, fever, or other signs of systemic inflammation, gastrointestinal symptoms, as well as in patients with worsening liver and/or renal function, and hepatic encephalopathy (Level A1). 

2. The diagnosis of SBP is based on neutrophil count in ascitic fluid of >250/mm3 as determined by microscopy (Level A1). 

3. Blood cultures should be performed in all patients with suspected SBP before starting antibiotic treatment (Level A1). 

4. Some patients may have an ascitic neutrophil count less than 250/mm3 but with a positive ascitic fluid culture. This condition is known as bacterascites. If the patient exhibits signs of systemic inflammation or infection, the patient should be treated with antibiotics (Level A1). 

5. Otherwise, the patient should undergo a second paracentesis when culture results come back positive. Patients in whom the repeat ascitic neutrophil count is >250/mm3 should be treated for SBP, and the remaining patients (i.e., neutrophils <250/mm3 ) should be followed up (Level B1). 

6. Spontaneous bacterial pleural empyema may complicate hepatic hydrothorax. Diagnostic thoracocentesis should be performed in patients with pleural effusion and suspected infection with inoculation of fluid into blood culture bottles (Level A1). 

7.The diagnosis is based on positive pleural fluid culture and increased neutrophil count of >250/mm3 or negative pleural fluid culture and >500 neutrophils/mm3 in the absence of pneumonia (Level B1). 

8. Patients with suspected secondary bacterial peritonitis should undergo appropriate radiological investigations such as CT scanning (Level A1). 

9.The use of other tests such as measurement of glucose or lactate dehydrogenase in an ascitic fluid cannot be recommended for the diagnosis of secondary bacterial peritonitis (Level B1).

10.SBP resolves with antibiotic therapy in approximately 90% of patients. Resolution of SBP should be proven by demonstrating a decrease of ascitic neutrophil count to <250/mm3 and sterile cultures of ascitic fluid, if positive at diagnosis (Level A1).

11.A second paracentesis after 48 h of start of treatment may help guide the effect of antibiotic therapy. Failure of antibiotic therapy should be suspected if there is worsening of clinical signs and symptoms and/or no marked reduction or increase in ascitic fluid neutrophil count compared to levels at diagnosis. The failure of antibiotic therapy is usually due to resistant bacteria or secondary bacterial peritonitis. Once secondary bacterial peritonitis has been excluded, antibiotics should be changed according to in vitro susceptibility of isolated organisms or modified to alternative empiric broad-spectrum agents (Level A1).
12. Spontaneous bacterial empyema should be managed similarly as SBP
13. all patients who develop SBP should be treated with broad-spectrum antibiotics and intravenous albumin (Level A2).

Prevention of secondary prophylaxis for those who had  SBP
Tab.Norfloxacin 400mg OD