Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document

Prognostic Importance of the Cause of Renal Failure in Patients With Cirrhosis

“…Renal failure was considered secondary to an infection when patients had an ongoing infection in the absence of other causes of renal failure. The following definitions of specific infections were used: spontaneous bacterial peritonitis was defined as the presence of a polymorphonuclear count greater than 250 per mm 3 in ascitic fluid in the absence of a source of infection in the peritoneal cavity 10 ; secondary bacterial peritonitis was defined as a polymorphonuclear count greater than 250 per mm 3 in ascitic fluid in the presence of inflammation or perforation of an abdominal organ 10 ; spontaneous bacteremia was defined in the presence of positive blood cultures without an evident source of infection; pneumonia, urinary tract infection, cellulitis, biliary tract infection, gastroenteritis, and meningitis were defined with standard diagnostic criteria; finally, culture-negative sepsis was defined as the presence of fever (Ͼ38°C), leukocytosis, or band forms together with negative cultures, requiring antibiotic therapy, after exclusion of conditions other than infection that could be responsible for the systemic inflammatory response. (2) Hypovolemia-related renal failure.…”

Characterisation of bacteria in ascites—reporting the potential of culture-independent, molecular analysis

“…Therefore, empirical antibiotic treatment for SBP is initiated when objective evidence of a local inflammatory reaction is present, i.e. an elevated ascites PMN count (≥250 cells/mm 3 ), without prior knowledge of the causative organisms or their antibiotic susceptibility [12]. Patients with a PMN count ≥250 cells/ mm 3 but whose ascites is culture-negative (sometimes referred to as culture-negative neutrocytic ascites [13]) have similar signs, symptoms and mortality as patients with SBP [12][13][14][15], suggesting the presence of bacterial species that are refractory to culture under standard conditions or that are present at relatively low concentrations [12].…”

Routine analysis of cirrhotic ascites for evidence of infection – not worth the effort?

“…Usually patients with SBP show symptoms such as fever, abdominal pain, worsening of renal function, hypotension or development of encephalopathy. The frequency of SBP among hospitalised patients with advanced cirrhosis varies from 10% to 30% [1]. The mortality of SBP was 80% to 100% in the 1960s, but has declined to 30% to 40% with early diagnosis and effective therapy with broad-spectrum antibiotics [2,3].…”

“…A high index of suspicion followed by analysis of ascitic fluid for evidence of infection is helpful in making an early diagnosis of SBP, and is today considered the standard of care in patients with cirrhosis and symptoms listed above. The International Ascites Club recommends mandatory analysis of ascitic fluid in all cases of new onset of ascites, worsening of ascites, and in all other cases whenever there is a suspicion of SBP [1].…”

“…The International Ascites Club recommends that all cases of SBP as also those with CNNA, whether symptomatic or asymptomatic, should be treated with broad spectrum antibiotics [1]. In patients with CNNA, other causes of PMN leukocytosis of ascitic fluid should be excluded (such as previous antibiotic therapy, hepatocellular carcinoma, peritoneal carcinomatosis, tuberculosis, pancreatitis and bleeding).…”