Suspected SBP
Cirrhosis + ascites + (fever, abdominal pain, encephalopathy, renal dysfunction, or leukocytosis)
All Pathways
GastroenterologyEmergency
Spontaneous Bacterial Peritonitis Management (AASLD 2021)
Spontaneous Bacterial Peritonitis Management (AASLD 2021): Suspected SBP → Diagnostic Paracentesis → SBP Diagnosis → Rule Out Secondary Peritonitis → ⚠️...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Diagnostic Paracentesis
Perform BEFORE antibiotics if possible
- Send: cell count with diff, culture (bedside inoculation)
- Also: protein, albumin, glucose, LDH
- Blood cultures x2
- No contraindication if INR or platelets abnormal
03Decision SBP Diagnosis
Ascitic fluid PMN ≥250 cells/mm³
- Culture-positive or culture-negative SBP
- Monomicrobial non-neutrocytic bacterascites (MNB): +culture, PMN <250
04Decision Rule Out Secondary Peritonitis
Runyon's criteria (≥2 of 3)
- Ascitic protein >1 g/dL
- Glucose <50 mg/dL
- LDH > upper limit of serum
- Polymicrobial culture
- If suspected: CT abdomen, surgical consult
05Warning ⚠️ Secondary Peritonitis
Urgent surgical evaluation
- Broad-spectrum antibiotics
- CT abdomen/pelvis
- Surgical source control
06Action Empiric Antibiotic Therapy
Start immediately after paracentesis
- Cefotaxime 2g IV q8h (preferred)
- OR Ceftriaxone 2g IV q24h
- Duration: 5 days (can extend to 7-10)
- Avoid aminoglycosides (nephrotoxicity)
07Action IV Albumin (HRS Prevention)
Required if Cr >1 or BUN >30 or bilirubin >4
- 1.5 g/kg on Day 1
- 1.0 g/kg on Day 3
- Reduces HRS and mortality by 60%+
- Consider for all hospitalized SBP
08Decision 48-Hour Reassessment
Repeat paracentesis if no improvement
- PMN should decrease by ≥25%
- Clinical improvement expected
09Action Clinical Improvement
Continue antibiotics for 5 days total
- Switch to PO if able (fluoroquinolone)
- No repeat paracentesis needed if improving
10Action Secondary Prophylaxis
After SBP episode, lifelong unless transplanted
- Norfloxacin 400mg PO daily (preferred)
- OR TMP-SMX DS daily
- OR Ciprofloxacin 500mg daily
- Also primary prophylaxis if: protein <1.5 + (Cr >1.2 OR Na <130 OR Child C)
11Outcome SBP Resolved
Continue prophylaxis, optimize cirrhosis management
12Outcome Transplant Evaluation
SBP indicates decompensated cirrhosis - MELD exception
13Warning Treatment Failure
Repeat paracentesis, broaden antibiotics
- Consider resistant organisms (ESBL, VRE)
- Piperacillin-tazobactam or carbapenem
- Re-evaluate for secondary peritonitis
- Consider fungal infection
- Path rejoins step 10Shared downstream outcome
- Path rejoins step 08Shared downstream outcome
- Path rejoins step 06Shared downstream outcome
Guideline Source
AASLD Practice Guidance on Ascites, Hepatorenal Syndrome, and SBP 2021
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Antibiotic choice should consider local resistance patterns
- Secondary bacterial peritonitis requires surgical evaluation
- HRS prevention requires early albumin
- Long-term prophylaxis indications evolving
Applicable Regions
USEUGlobal
EU: EASL guidelines are similar
US: AASLD 2021 is current standard
Version 1Next review: 2027-01-01
Next steps
Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.
Calculator
Glasgow-Blatchford Bleeding Score
Upper GI bleed risk stratification and need for intervention
Open page
Compare
AttendMe.ai vs UpToDate
See how this pathway workflow compares against UpToDate.
Open page
Commercial
Start free
Run the pathway in a live AttendMe account with citations and tracked usage.
Start free
Related Resources
Frequently Asked Questions
What is the Spontaneous Bacterial Peritonitis Management (AASLD 2021)?
The Spontaneous Bacterial Peritonitis Management (AASLD 2021) is a emergency clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on AASLD Practice Guidance on Ascites, Hepatorenal Syndrome, and SBP 2021.
What guideline is the Spontaneous Bacterial Peritonitis Management (AASLD 2021) based on?
This algorithm is based on AASLD Practice Guidance on Ascites, Hepatorenal Syndrome, and SBP 2021 (DOI: 10.1002/hep.32327).
What are the limitations of the Spontaneous Bacterial Peritonitis Management (AASLD 2021)?
Known limitations include: Antibiotic choice should consider local resistance patterns; Secondary bacterial peritonitis requires surgical evaluation; HRS prevention requires early albumin; Long-term prophylaxis indications evolving. Individual patient factors may require deviation from these recommendations.
Get AI-Powered Analysis Alongside This Algorithm
In AttendMe.ai, the Spontaneous Bacterial Peritonitis Management (AASLD 2021) appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.
Try AttendMe Free