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Spontaneous bacterial peritonitis: recent guidelines and beyond
  1. R Wiest1,
  2. A Krag2,
  3. A Gerbes3
  1. 1Department for visceral surgery and medicine, University Hospital Bern, Switzerland
  2. 2Department of Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
  3. 3Klinikum of the University of Munich, Munich, Germany
  1. Correspondence to Professor Dr Reiner Wiest, Department for visceral surgery and medicine, University Hospital Bern, 3010 Bern, Switzerland; reiner.wiest{at}insel.ch

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Introduction

Spontaneous bacterial peritonitis (SBP) is the most frequent and life-threatening infection in patients with liver cirrhosis requiring prompt recognition and treatment. It is defined by the presence of >250 polymorphonuclear cells (PMN)/mm3 in ascites in the absence of an intra-abdominal source of infection or malignancy. In this review we discuss the current opinions reflected by recent guidelines (American Association for the Study of Liver Diseases, European Association for the Study of the Liver, Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten),1–4 with particular focus on controversial issues as well as open questions that need to be addressed in the future. First, diagnostic criteria and tools available for rapid and accurate diagnosis are reviewed. Second, since prophylaxis is of crucial relevance when trying to improve survival, we discuss who should be treated, when, how and for how long to prevent episodes of SBP. Identification of risk factors and individualisation of timing and selection of prophylactic measures are the key to success without major development of resistant bacteria. Finally, effective therapy is essential since treatment failure is associated with poor outcome. Since the emergence and spread of drug-resistant bacteria has accelerated, criteria for the choice of antibiotic regimen in the individual patient are pivotal for optimising therapy.

Epidemiology and prognosis of SBP

SBP is the most frequent bacterial infection in cirrhosis, accounting for 10–30% of all reported bacterial infections in hospitalised patients.5–7 In outpatients without symptoms the prevalence is low (3.5%8 or lower9 10), but the prevalence increases in the nosocomial setting, ranging from 8% to 36%.11 12 Bacterascites, defined as positive culture results but no increase in the PMN count in the ascitic fluid, occurs with a prevalence of 2–3% in outpatients8–10 and in up to 11% …

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