Spontaneous bacterial peritonitis
ICD-10 K65.2 · ICD-11 DC50.00

Community-Acquired Spontaneous Bacterial Peritonitis in Adults Not Responding to Initial Antibiotic Therapy

Clinical scenario

Adults (age ≥18) with community-acquired spontaneous bacterial peritonitis diagnosed by ascitic fluid polymorphonuclear leukocyte (PMN) count >250/mm³, without nosocomial or healthcare-associated infection and without sepsis or septic shock.

First-line treatment — failure condition

Initial empirical therapy with an IV third-generation cephalosporin did not achieve the required response: ascitic fluid PMN count did not decrease by at least 25% from baseline on diagnostic paracentesis performed 48 hours after starting antibiotic treatment.

This protocol defines the next step when that response threshold is not met.

Next-step approach

When the 48-hour PMN response criterion is not achieved, management involves broadening antibiotic coverage to agents with a wider spectrum. Evaluation to exclude secondary bacterial peritonitis is also warranted. The full antibiotic selection and clinical algorithm are available in the complete protocol.

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References

DOI: 10.1002/hep.31884

  1. The diagnosis of SBP/SBE is established with a fluid polymorphonuclear (PMN) leukocyte count >250/mm³.
  2. First-line empirical antibiotic therapy for community-acquired SBP/SBE is IV third-generation cephalosporin.
  3. A negative response is defined by a decrease in PMN count <25% from baseline and should lead to broadening the antibiotic spectrum and investigating secondary peritonitis (abdominal imaging studies).
  4. A decrease in fluid PMN <25% from baseline indicates lack of response and should lead to broadening of antibiotic coverage and further evaluation to rule out secondary bacterial peritonitis.
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