Spontaneous bacterial peritonitis classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Shivani Chaparala M.B.B.S [3] Ahmed Younes M.B.B.CH [4]


Spontaneous bacterial peritonitis is one variant of ascitic fluid infections.[1] Classification of ascitic fluid infections is based on neutrophil count and culture report.[2][3] Asymptomatic bacterascites is usually the transient residence of bacteria in ascitic fluid without clinical features of peritonitis or increased ascitic fluid polymorphonuclear cells.[4] SBP is also classified based on the routes of infection and the clinical setting as follows health care-associated, nosocomial, community acquired, multi-drug resistant and recurrent.


Type of Infection Bacterial Culture Report Ascitic fluid analysis Neutrophil Count (cells/mm3) Clinical aspects
Spontaneous bacterial peritonitis[5] Positive usually for one organism ≥250 Patients with cirrhosis and ascites in the presence or absence of symptoms and signs
Culture negative neutrocytic ascites (CNNA)[6][7] Negative ≥250 Poor culture technique and prior antibiotics or low opsonic activity in ascitic fluid. Commonly encountered phenotype and requires antibiotic therapy.
Monomicrobial bacterascites[8] Positive for one organism <250 Ascitic fluid infection which may resolve spontaneously or progress to SBP. Mortality is similar to SBP and should be treated as SBP.
Secondary bacterial peritonitis Positive for many microbes ≥250 Intraperitoneal source of infection e.g. diverticulitis
Polymicrobial bacterascites[9] Positive for many microbes <250 Usually due to bowel perforation by the paracentesis needle and reflects growth of gut flora before the ascitic fluid can mount a neutrocytic response.

Classification Based on Clinical Setting

Based on the route of infection SBP is classified as follows:[2][10]

Clinical setting associated with SBP Criteria
Health care-associated SBP (HCA)
  • Diagnosis of peritonitis within 48 hours of hospital admission in patients with any prior health care contact in the past 90 days (e.g. recent hospitalisation, nursing home, dialysis centers and other health care setting)
Nosocomial SBP
Community acquired SBP (CA)
  • Diagnosis of peritonitis within 48 hours of hospital admission, but no history of prior health care contact in the past 90 days. Predominantly caused by gram-negative bacteria.
Multi-drug resistant SBP
Recurrent SBP


  1. 1.0 1.1 Sheer TA, Runyon BA (2005). "Spontaneous bacterial peritonitis". Dig Dis. 23 (1): 39–46. doi:10.1159/000084724. PMID 15920324.
  2. 2.0 2.1 2.2 Dever JB, Sheikh MY (2015) Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther 41 (11):1116-31. DOI:10.1111/apt.13172 PMID: 25819304
  3. 3.0 3.1 Runyon BA, AASLD Practice Guidelines Committee (2009). "Management of adult patients with ascites due to cirrhosis: an update". Hepatology. 49 (6): 2087–107. doi:10.1002/hep.22853. PMID 19475696.
  4. 4.0 4.1 Pelletier G, Lesur G, Ink O, Hagege H, Attali P, Buffet C; et al. (1991). "Asymptomatic bacterascites: is it spontaneous bacterial peritonitis?". Hepatology. 14 (1): 112–5. PMID 2066060.
  5. Kim SU, Kim DY, Lee CK, Park JY, Kim SH, Kim HM; et al. (2010). "Ascitic fluid infection in patients with [[hepatitis B]] virus-related liver [[cirrhosis]]: culture-negative neutrocytic ascites versus spontaneous bacterial [[peritonitis]]". J Gastroenterol Hepatol. 25 (1): 122–8. doi:10.1111/j.1440-1746.2009.05970.x. PMID 19845823. URL–wikilink conflict (help)
  6. Pelletier G, Salmon D, Ink O, Hannoun S, Attali P, Buffet C; et al. (1990). "Culture-negative neutrocytic ascites: a less severe variant of spontaneous bacterial peritonitis". J Hepatol. 10 (3): 327–31. PMID 2365982.
  7. Runyon BA, Hoefs JC (1984). "Culture-negative neutrocytic ascites: a variant of spontaneous bacterial peritonitis". Hepatology. 4 (6): 1209–11. PMID 6500513.
  8. Runyon BA (1990). "Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis". Hepatology. 12 (4 Pt 1): 710–5. PMID 2210672.
  9. Runyon BA, Hoefs JC, Canawati HN (1986). "Polymicrobial bacterascites. A unique entity in the spectrum of infected ascitic fluid". Arch Intern Med. 146 (11): 2173–5. PMID 3778046.
  10. Fernández, J (2002). "Bacterial infections in cirrhosis: Epidemiological changes with invasive procedures and norfloxacin prophylaxis". Hepatology. 35 (1): 140–148. doi:10.1053/jhep.2002.30082. ISSN 0270-9139.