Spontaneous Bacterial Peritonitis and Spontaneous Bacterial Pleuritis

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Top tips:

  1. Speed is life in cirrhosis when infection is suspected. Early and Appropriate antibiotics reduce mortality.
  2. Paracentesis and Thoracentesis before antibiotics is ideal. But, if you have a high suspicion of infection and these cannot be arranged in a timely manner, do not delay antibiotics.
  3. You must consider risk factors for multi-drug resistance (i.e. recent hospitalizations, colonization with multi-drug resistant organisms, nursing home resident) when choosing your antibiotics.
  4. De-escalate/narrow antibiotics as soon as a pathogen is identified on culture.
  5. All patients should be started on secondary prophylaxis with antibiotics once a diagnosis of SBPeritonitis or SBPleuritis is made. In patients with low protein ascites (<1.5 g/L), primary SBP prophylaxis does not change mortality, but could be considered in those at high risk (renal dysfunction – creatinine level ≥1.2 mg/dL (106 umol/L), BUN ≥ 25 mg/dL, sodium l 130 mEq/L) or liver failure (Child Pugh score ≥9 and bilirubin ≥3 mg/dL (51.3 umol/L))

Order panel for SB Peritonitis or SB Pleuritis:

For adults with cirrhosis admitted with Spontaneous Bacterial Peritonitis (ascites PMN >250 cells/µL) or Spontaneous Bacterial Pleuritis (pleural fluid PMN >500 cells/µL or >250 cells/µL with positive culture):
 SB-Peritonitis-Pleuritis Order Panel

Thank you to Dr. Saxinger for your efforts creating the content on this page!


Specific Management

Patient materials:

You can direct patients to the following:

Lab tests

Downloadable content:

You can download these to print or view offline:
EASL Guidelines


This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.
Authors: Dr. Lynora Saxinger, Dr. Dean Karvellas, Dr. Uma Chandran, Dr. Puneeta Tandon

  1. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018 Aug;69(2):406-460 PMID 29653741
  2. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology (Baltimore, Md.)74(2), 1014–1048. https://doi.org/10.1002/hep.31884 PMID 33942342
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