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hep.spontaneous-bacterial-peritonitis.core.v1PRODUCTION
hep.spontaneous-bacterial-peritonitis.core.v1

Spontaneous Bacterial Peritonitis

hepatologyacuteadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm SBP scope: cirrhotic with ascites + ascitic PMN >=250/mm^3; distinguish from secondary peritonitis (AASLD 2021)

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Advance rule
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Advance when

SBP suspected or confirmed

Patient inputs (18)

Elderly higher mortality; antibiotic dosing adjustment (AASLD 2021)

Fever common; absent in 30% of SBP (AASLD 2021)

Hypotension - sepsis screen; HRS-AKI risk (AASLD 2021)

Tachycardia - SIRS/sepsis (AASLD 2021)

Prior SBP - mandatory secondary prophylaxis; recurrence ~70%/yr without (Fernandez 2007)

Resistance pattern - if on prophylaxis ESBL/quinolone-resistant likely (AASLD 2021)

Nosocomial vs community - alters empiric coverage (AASLD 2021)

Hold NSBB during SBP with hypotension; Baveno VII caution (AASLD 2021)

PMN >=250/mm^3 = SBP diagnostic per AASLD 2021

Culture-positive SBP vs culture-negative neutrocytic ascites (CNNA); bedside inoculation 10 mL into BCB increases yield (AASLD 2021)

Low protein <1.5 g/dL = high SBP risk; primary prophylaxis criterion (Fernandez 2007 PMID 17854593)

SAAG >=1.1 confirms portal hypertensive ascites; distinguishes from secondary peritonitis (AASLD 2021)

Sort 1999 criterion (Cr >1.0); HRS-AKI screening; albumin indication (Sort 1999 PMID 10432325)

Sort 1999 criterion (BUN >30); albumin indication (Sort 1999)

Sort 1999 criterion (bili >4); albumin indication (Sort 1999)

Leukocytosis suggests infection; cirrhotics often blunted response (AASLD 2021)

Cirrhosis severity; paracentesis bleeding risk (low) (AASLD 2021)

Sepsis severity marker (AASLD 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningseptic_shock_in_sbp
    MAP <65 despite 20-30 mL/kg fluids OR lactate >4 mmol/L in SBP (Surviving Sepsis 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsecondary_peritonitis_suspected
    Runyon criteria - any 2 of (ascitic glucose <50, LDH > serum upper limit, total protein >1 g/dL, polymicrobial gram stain) (AASLD 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresbp_diagnosed
    Ascitic PMN >=250/mm^3 in cirrhotic with ascites (AASLD 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresbp_with_sort_criteria
    SBP + (Cr >1.0 mg/dL OR BUN >30 mg/dL OR total bilirubin >4 mg/dL) (Sort 1999)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenosocomial_sbp
    SBP onset >=48h post-admission OR on quinolone prophylaxis OR recent healthcare exposure (AASLD 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_sbp
    Second or more SBP episode (AASLD 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

SBP - empiric ceftriaxone + albumin (if Sort criteria) + secondary prophylaxis (AASLD 2021; Sort 1999; Fernandez 2007)
axis: sbp_treatment_and_prophylaxis_pathwaystep 1 - Step 1 - Empiric antibiotic (community-acquired SBP)
Selected step "Step 1 - Empiric antibiotic (community-acquired SBP)" — Ascitic PMN >=250/mm^3 + community-acquired (not on quinolone prophylaxis, no recent healthcare exposure)
  • ceftriaxone
    first line
    cephalosporin_3rd_gen
    2 g IV daily x 5-7 days • IV • daily
    triggers: community_acquired_SBP, PMN_>=250
    AASLD 2021 first-line for community-acquired SBP (PMID 33942342); narrower than cefotaxime per current resistance patterns
    rxcui 2193
  • cefotaxime
    first line
    cephalosporin_3rd_gen
    2 g IV q8h x 5-7 days • IV • q8h
    triggers: community_acquired_SBP_ceftriaxone_unavailable
    Original Sort 1999 regimen (PMID 10432325); equivalent to ceftriaxone
    rxcui 2186

ed playbook — drug actions (5)

  1. 1. ceftriaxone empiric community-acquired
    2 g IV daily • IV • daily
    trigger: PMN >=250 + community-acquired (AASLD 2021)
    First-line empiric
  2. 2. piperacillin-tazobactam nosocomial
    4.5 g IV q6h • IV • q6h
    trigger: Nosocomial OR on quinolone prophylaxis OR healthcare-associated (AASLD 2021)
    Broad-spectrum for nosocomial SBP
  3. 3. albumin if Sort criteria
    1.5 g/kg IV day 1 (max 150 g) • IV • one dose then second day 3
    trigger: Cr >1.0 OR BUN >30 OR bili >4 (Sort 1999 PMID 10432325)
    Reduces HRS-AKI mortality
  4. 4. crystalloid resuscitation for sepsis
    20-30 mL/kg IV LR over 3h (use cautious volumes in cirrhosis) • IV • bolus
    trigger: Sepsis with hypotension (Surviving Sepsis 2021)
    Cautious volume in cirrhosis - prefer albumin + vasopressor if SBP+shock
  5. 5. norepinephrine for septic shock
    0.05-0.5 mcg/kg/min titrated • IV • continuous
    trigger: MAP <65 despite fluids (Surviving Sepsis 2021)
    First-line vasopressor

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Fever, chills, or abdominal pain in cirrhotic with ascites (AASLD 2021); New or worsening encephalopathy in cirrhotic with ascites (AASLD 2021); New AKI in cirrhotic with ascites (AASLD 2021).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Spontaneous Bacterial Peritonitis** (hep.spontaneous-bacterial-peritonitis.core.v1).
Phenotype framing: Distinguish SBP from secondary peritonitis (bowel perforation, intra-abdominal abscess), TB peritonitis, malignant ascites with bacterial superinfection, pancreatic ascites (AASLD 2021)
Scope: Confirm SBP scope: cirrhotic with ascites + ascitic PMN >=250/mm^3; distinguish from secondary peritonitis (AASLD 2021)

No severity triggers fired against current inputs.

Plan

Regimen axis: **SBP - empiric ceftriaxone + albumin (if Sort criteria) + secondary prophylaxis (AASLD 2021; Sort 1999; Fernandez 2007)** — step "Step 1 - Empiric antibiotic (community-acquired SBP)".
1. ceftriaxone 2 g IV daily x 5-7 days IV daily (cephalosporin_3rd_gen, first line) — AASLD 2021 first-line for community-acquired SBP (PMID 33942342); narrower than cefotaxime per current resistance patterns
2. cefotaxime 2 g IV q8h x 5-7 days IV q8h (cephalosporin_3rd_gen, first line) — Original Sort 1999 regimen (PMID 10432325); equivalent to ceftriaxone

Setting playbook (ed) — Recognize SBP risk in cirrhotic with ascites, perform diagnostic paracentesis, start empiric antibiotics, add albumin if Sort criteria, admit (AASLD 2021)
3. ceftriaxone empiric community-acquired 2 g IV daily IV daily — PMN >=250 + community-acquired (AASLD 2021) (First-line empiric)
4. piperacillin-tazobactam nosocomial 4.5 g IV q6h IV q6h — Nosocomial OR on quinolone prophylaxis OR healthcare-associated (AASLD 2021) (Broad-spectrum for nosocomial SBP)
5. albumin if Sort criteria 1.5 g/kg IV day 1 (max 150 g) IV one dose then second day 3 — Cr >1.0 OR BUN >30 OR bili >4 (Sort 1999 PMID 10432325) (Reduces HRS-AKI mortality)
6. crystalloid resuscitation for sepsis 20-30 mL/kg IV LR over 3h (use cautious volumes in cirrhosis) IV bolus — Sepsis with hypotension (Surviving Sepsis 2021) (Cautious volume in cirrhosis - prefer albumin + vasopressor if SBP+shock)
7. norepinephrine for septic shock 0.05-0.5 mcg/kg/min titrated IV continuous — MAP <65 despite fluids (Surviving Sepsis 2021) (First-line vasopressor)

Non-pharmacologic actions:
- IV access x 2 (AASLD 2021)
- NPO if surgery considered for secondary peritonitis (AASLD 2021)
- HOLD NSBB if hypotensive (Baveno VII 2022)
- HOLD nephrotoxins (NSAIDs, contrast, aminoglycoside) (AASLD 2021)
- Hepatology consult on admission (AASLD 2021)
- Surgery consult if secondary peritonitis suspected (AASLD 2021)

AVOID / contraindication checks:
- Hold_NSBB_during_SBP_with_hypotension_or_HRS (Baveno VII 2022)
- NSAID_avoid_HRS_GI_bleed_risk (AASLD 2021)
- Aminoglycoside_avoid_HRS_risk (AASLD 2021)
- Nephrotoxin_avoid_during_SBP (AASLD 2021)
- Fluoroquinolone_secondary_prophylaxis_indefinite_until_transplant_or_persistent_ascites_resolution (Fernandez 2007 PMID 17854593)
- Do_not_use_third_gen_cephalosporin_alone_in_nosocomial_SBP (AASLD 2021)
- Repeat_paracentesis_at_48h_only_if_atypical_response (AASLD 2021)

Monitoring

Regimen monitoring:
- daily Cr BUN Na K bilirubin INR (AASLD 2021)
- daily HE grading West Haven (AASLD 2021)
- daily weights and ascites assessment (AASLD 2021)
- culture followup and de escalation at 48 72h (AASLD 2021)
- repeat paracentesis at 48h ONLY if clinical concern (AASLD 2021)
- temperature q4h (AASLD 2021)
- duration 5 to 7 days after defervescence (AASLD 2021)
- check NSBB holds (Baveno VII 2022)
- transplant referral if MELD >=15 or recurrent SBP (AASLD 2021)

Setting (ed) monitoring:
- Continuous SpO2 + telemetry (AASLD 2021)
- Lactate q2-4h in sepsis (AASLD 2021)
- Hourly UOP in shock or HRS (AASLD 2021)
- Repeat HE grading q4h (AASLD 2021)

Follow-up plan: Secondary prophylaxis NORFLOXACIN 400 mg PO daily (or ciprofloxacin 500 mg daily or TMP/SMX DS daily) lifelong or until transplant (Fernandez 2007 PMID 17854593); transplant evaluation; HCC surveillance; hepatology q1-3mo (AASLD 2021)
- Close-out criterion: prophylaxis started + follow-up scheduled

Monitoring phase: Repeat diagnostic paracentesis at 48h ONLY if atypical (suspected resistance, slow response, secondary peritonitis suspicion); daily Cr, Na, K, INR, bilirubin, WBC; daily HE grading; weights (AASLD 2021)

Disposition

Current setting: ed — Recognize SBP risk in cirrhotic with ascites, perform diagnostic paracentesis, start empiric antibiotics, add albumin if Sort criteria, admit (AASLD 2021)

Disposition criteria:
- Admit floor: SBP without organ failure or shock (AASLD 2021)
- Admit ICU: septic shock, HRS-AKI, HE 3-4 (AASLD 2021)
- OR for secondary peritonitis (AASLD 2021)

Escalation triggers (move to higher acuity):
- Septic shock - ICU + vasopressors (Surviving Sepsis 2021)
- HRS-AKI evolving - ICU + terlipressin + albumin (CONFIRM 2022)
- HE grade 3-4 with airway compromise - ICU + intubation (AASLD 2021)
- Secondary peritonitis - surgery + broad-spectrum + source control (AASLD 2021)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] MAP <65 despite 20-30 mL/kg fluids OR lactate >4 mmol/L in SBP (Surviving Sepsis 2021)
- [LIFE_THREATENING] Runyon criteria - any 2 of (ascitic glucose <50, LDH > serum upper limit, total protein >1 g/dL, polymicrobial gram stain) (AASLD 2021)
- [SEVERE] Ascitic PMN >=250/mm^3 in cirrhotic with ascites (AASLD 2021)

Citations

- AASLD 2021 Practice Guidance: Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome (Biggins, Hepatology 2021) [PMID:33942342](https://pubmed.ncbi.nlm.nih.gov/33942342/)
- Cited evidence (PMID 10432325) [PMID:10432325](https://pubmed.ncbi.nlm.nih.gov/10432325/)
- Cited evidence (PMID 17854593) [PMID:17854593](https://pubmed.ncbi.nlm.nih.gov/17854593/)

Last reconciled with current guidelines: 2026-05-26.
References
  • AASLD 2021 Practice Guidance: Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome (Biggins, Hepatology 2021) — PMID:33942342
  • Cited evidence (PMID 10432325) — PMID:10432325
  • Cited evidence (PMID 17854593) — PMID:17854593