Liver cirrhosis complicated by community-acquired spontaneous bacterial peritonitis (SBP), defined by an ascitic fluid neutrophil count above 250 cells/mm³. This protocol applies when empirical first-line antibiotic treatment has been initiated but the required degree of neutrophil count reduction has not been achieved.
The initial empirical regimen — intravenous third-generation cephalosporin plus albumin (or, in settings with high bacterial resistance rates, piperacillin/tazobactam or carbapenem) — is considered to have failed when the ascitic fluid neutrophil count does not fall by at least 25% at 48 hours, or does not fall below 250/mm³ by day seven. When these targets are not met, a different antibiotic strategy is required.
The next step involves modifying antibiotic therapy — either guided by culture results and in vitro sensitivity data, or adjusted on an empirical basis. The full structured regimen, including the specific decision pathway and sequencing, is available via the protocol link below.
The diagnosis of SBP is based on neutrophil count in ascitic fluid of >250/mm³ (II-2;1).
Third-generation cephalosporins are recommended as first-line antibiotic treatment for community-acquired SBP in countries with low rates of bacterial resistance (I;1).
De-escalation according to bacterial susceptibility based on positive cultures is recommended to minimise resistance selection pressure (II-2;1).
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