Spontaneous bacterial peritonitis medical therapy: Difference between revisions
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Empiric broad-spectrum [[intravenous]] [[antibiotic]], preferably with a third generation [[cephalosporin]] such as [[cefotaxime]], is warranted for suspected or established [[spontaneous bacterial peritonitis|spontaneous bacterial peritonitis (SBP)]] to cover the most common isolates including ''[[Escherichia coli]]'', ''[[Klebsiella pneumoniae]]'', and ''[[Streptococcus pneumoniae]]''. Oral [[ofloxacin]] may be considered in selected cases. [[Albumin]] should be reserved for patients with [[ascites|ascitic fluid]] [[PMN]] counts greater than or equal to 250 cells/mm<sup>3</sup> and clinical suspicion of SBP, who also have a serum [[creatinine]] >1 mg/dL, [[blood urea nitrogen]] >30 mg/dL, or total [[bilirubin]] >4 mg/dL. | Empiric broad-spectrum [[intravenous]] [[antibiotic]], preferably with a third generation [[cephalosporin]] such as [[cefotaxime]], is warranted for suspected or established [[spontaneous bacterial peritonitis|spontaneous bacterial peritonitis (SBP)]] to cover the most common isolates including ''[[Escherichia coli]]'', ''[[Klebsiella pneumoniae]]'', and ''[[Streptococcus pneumoniae]]''. Oral [[ofloxacin]] may be considered in selected cases. [[Albumin]] should be reserved for patients with [[ascites|ascitic fluid]] [[PMN]] counts greater than or equal to 250 cells/mm<sup>3</sup> and clinical suspicion of SBP, who also have a serum [[creatinine]] >1 mg/dL, [[blood urea nitrogen]] >30 mg/dL, or total [[bilirubin]] >4 mg/dL. | ||
== | ==Empiric Therapy <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''AASLD Practice Guidelines: Management of Adult Patients with Ascites Due to Cirrhosis''.<ref name=AASLD2012>{{cite web | ||
| title = Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012 | |||
| url = http://www.aasld.org/practiceguidelines/Documents/ascitesupdate2013.pdf | |||
}}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>== | |||
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* The diagnosis of spontaneous bacterial peritonitis (SBP) is made in the presence of an elevated [[ascites|ascitic fluid]] absolute [[PMN|polymorphonuclear leukocyte (PMN)]] count (i.e., ≥250 cells/ mm<sup>3</sup> without an evident intra-abdominal, surgically treatable source of infection. | |||
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{| style="float: right; cellpadding=0; cellspacing= 0; width: 400px;" | |||
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Spontaneous Bacterial Peritonitis}} | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q8h (or 2 g IV q4h if life-threatening)'''''<BR> OR <BR> ▸ '''''[[Ticarcillin clavulanate|Ticarcillin–Clavulanate]] 3.1 g IV q4–6h'''''<BR> OR <BR> ▸ '''''[[Piperacillin-tazobactam|Piperacillin–Tazobactam]] 3.375 g IV q6h (or 4.5 g IV q8h)'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 1–2 g IV q12–24h'''''<BR> OR <BR> ▸ '''''[[Ertapenem]] 1 g IV q24h''''' | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | For [[ESBL]]–producing ''[[Enterobacteriaceae]]'', check susceptibility testing. | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Doripenem]] 500 mg IV q8h (1–hr infusion)'''''<BR> OR <BR> ▸ '''''[[Ertapenem]] 1 g IV q24h'''''<BR> OR <BR> ▸ '''''[[Imipenem cilastatin|Imipenem–Cilastatin]] 0.5–1 g IV q6–8h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 1 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 400 mg IV q12h'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h''''' | |||
|} | |||
* Empiric antibiotic therapy should be administered to patients with [[ascites|ascitic fluid]] [[PMN]] counts greater than or equal to 250 cells/mm<sup>3</sup> in a clinical setting compatible with [[ascites|ascitic fluid]] [[infection]] or those who have convincing signs or symptoms of infection ([[fever]], [[abdominal pain]], or unexplained [[encephalopathy]]) regardless of the [[PMN]] count in the [[ascites|ascitic fluid]].<ref>{{Cite journal | |||
| doi = 10.1002/hep.26359 | |||
| issn = 1527-3350 | |||
| volume = 57 | |||
| issue = 4 | |||
| pages = 1651–1653 | |||
| last = Runyon | |||
| first = Bruce A | |||
| coauthors = AASLD | |||
| title = Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012 | |||
| journal = Hepatology (Baltimore, Md.) | |||
| date = 2013-04 | |||
| pmid = 23463403 | |||
}}</ref><ref>{{Cite journal | |||
| issn = 0270-9139 | |||
| volume = 2 | |||
| issue = 4 | |||
| pages = 399–407 | |||
| last = Hoefs | |||
| first = J C | |||
| coauthors = H N Canawati, F L Sapico, R R Hopkins, J Weiner, J Z Montgomerie | |||
| title = Spontaneous bacterial peritonitis | |||
| journal = Hepatology (Baltimore, Md.) | |||
| date = 1982-08 | |||
| pmid = 7095741 | |||
}}</ref> | |||
* The 3 most common isolates from the [[ascites|ascitic fluid]] are ''[[Escherichia coli]]'', ''[[Klebsiella pneumoniae]]'', and ''[[Streptococcus pneumoniae]]''. | |||
* Relatively broad-spectrum therapy, preferably with [[cefotaxime]], is warranted until the results of susceptibility testing are available. | |||
* Infection with [[MDR|multiresistant]] organism including [[ESBL|Extended-spectrum β-lactamase (ESBL)]]-producing ''[[Enterobacteriaceae]]'', ''[[Pseudomonas aeruginosa]]'', [[MRSA|methicillin-resistant ''Staphylococcus aureus (MRSA)'']], and ''[[Enterococcus faecium]]'' is associated with an increased [[mortality]]. [[Risk factor]]s for [[MDR|multiresistant]] infections include:<ref>{{Cite journal | |||
| doi = 10.1002/hep.25532 | |||
| issn = 1527-3350 | |||
| volume = 55 | |||
| issue = 5 | |||
| pages = 1551–1561 | |||
| last = Fernández | |||
| first = Javier | |||
| coauthors = Juan Acevedo, Miriam Castro, Orlando Garcia, Carlos Rodríguez de Lope, Daria Roca, Marco Pavesi, Elsa Sola, Leticia Moreira, Anibal Silva, Tiago Seva-Pereira, Francesco Corradi, Jose Mensa, Pere Ginès, Vicente Arroyo | |||
| title = Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study | |||
| journal = Hepatology (Baltimore, Md.) | |||
| date = 2012-05 | |||
| pmid = 22183941 | |||
}}</ref> | |||
:* [[Nosocomial]] origin of infection | |||
:* Long-term [[norfloxacin]] prophylaxis | |||
:* Recent infection with [[MDR|multiresistant]] bacteria | |||
:* Recent use of [[beta-lactam]]s | |||
* Oral [[ofloxacin]] may be used alternatively in selected cases such as patients without [[vomiting]], [[shock]], grade II (or higher) [[hepatic encephalopathy]], or serum [[creatinine]] greater than 3 mg/dL.<ref>{{Cite journal | |||
| issn = 0016-5085 | |||
| volume = 111 | |||
| issue = 4 | |||
| pages = 1011–1017 | |||
| last = Navasa | |||
| first = M | |||
| coauthors = A Follo, J M Llovet, G Clemente, V Vargas, A Rimola, F Marco, C Guarner, M Forné, R Planas, R Bañares, L Castells, M T Jimenez De Anta, V Arroyo, J Rodés | |||
| title = Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis | |||
| journal = Gastroenterology | |||
| date = 1996-10 | |||
| pmid = 8831596 | |||
}}</ref> | |||
== | ==Adjunctive Therapy== | ||
=== | * [[Albumin]] infusion should be administered to [[cirrhosis|cirrhotic]] patients with [[spontaneous bacterial peritonitis]] in the following conditions:<ref>{{Cite journal | ||
| doi = 10.1136/gut.2006.113050 | |||
| issn = 0017-5749 | |||
* | | volume = 56 | ||
* | | issue = 4 | ||
* [[ | | pages = 597–599 | ||
| last = Sigal | |||
| first = Samuel H | |||
| coauthors = Carmen M Stanca, Javier Fernandez, Vicente Arroyo, Miguel Navasa | |||
| title = Restricted use of albumin for spontaneous bacterial peritonitis | |||
| journal = Gut | |||
| date = 2007-04 | |||
| pmid = 17369392 | |||
| pmc = PMC1856861 | |||
}}</ref> | |||
:* Serum [[creatinine]]> 1 mg/dL | |||
:* [[Blood urea nitrogen]] >30 mg/dL | |||
:* Total [[bilirubin]] >4 mg/dL | |||
* Adjunctive [[intravenous]] [[albumin]] at a dose of 1.5 g/kg at the time of diagnosis, followed by 1 g/kg on day 3 is associated with a reduced incidence of [[renal impairment]] and [[death]] in comparison with treatment with an [[antibiotic]] alone.<ref>{{Cite journal | |||
* [[ | | doi = 10.1056/NEJM199908053410603 | ||
| issn = 0028-4793 | |||
| volume = 341 | |||
| issue = 6 | |||
| pages = 403–409 | |||
| last = Sort | |||
| first = P | |||
| coauthors = M Navasa, V Arroyo, X Aldeguer, R Planas, L Ruiz-del-Arbol, L Castells, V Vargas, G Soriano, M Guevara, P Ginès, J Rodés | |||
| title = Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis | |||
| journal = The New England journal of medicine | |||
| date = 1999-08-05 | |||
| pmid = 10432325 | |||
}}</ref> | |||
* The use of non-selective [[beta blockers]] in [[cirrhosis|cirrhotic]] patients with SBP should be discouraged since it is associated with an increased risk for [[hemodynamic compromise]], prolonged [[hospitalization]], [[hepatorenal syndrome]], [[acute kidney injury]].<ref>{{Cite journal | |||
| doi = 10.1053/j.gastro.2014.03.005 | |||
| issn = 1528-0012 | |||
| volume = 146 | |||
| issue = 7 | |||
| pages = 1680–1690.e1 | |||
| last = Mandorfer | |||
| first = Mattias | |||
| coauthors = Simona Bota, Philipp Schwabl, Theresa Bucsics, Nikolaus Pfisterer, Matthias Kruzik, Michael Hagmann, Alexander Blacky, Arnulf Ferlitsch, Wolfgang Sieghart, Michael Trauner, Markus Peck-Radosavljevic, Thomas Reiberger | |||
| title = Nonselective β Blockers Increase Risk for Hepatorenal Syndrome and Death in Patients With Cirrhosis and Spontaneous Bacterial Peritonitis | |||
| journal = Gastroenterology | |||
| date = 2014-06 | |||
| pmid = 24631577 | |||
}}</ref> | |||
---- | |||
---- | |||
===Guidelines === | ===Guidelines=== | ||
* Patients with [[ascites]] admitted to the hospital should undergo abdominal paracentesis. [[Paracentesis]] should be repeated in patients who develop signs or symptoms or laboratory abnormalities suggestive of infection.<ref name="urlNational Guideline Clearinghouse | Management of adult patients with ascites due to cirrhosis: an update.">{{cite web |url=http://guideline.gov/content.aspx?id=14887&search=ascitis |title=National Guideline Clearinghouse | Management of adult patients with ascites due to cirrhosis: an update. |format= |work= |accessdate=}}</ref> | * Patients with [[ascites]] admitted to the hospital should undergo abdominal paracentesis. [[Paracentesis]] should be repeated in patients who develop signs or symptoms or laboratory abnormalities suggestive of infection.<ref name="urlNational Guideline Clearinghouse | Management of adult patients with ascites due to cirrhosis: an update.">{{cite web |url=http://guideline.gov/content.aspx?id=14887&search=ascitis |title=National Guideline Clearinghouse | Management of adult patients with ascites due to cirrhosis: an update. |format= |work= |accessdate=}}</ref> | ||
Line 66: | Line 152: | ||
* Patients with ascitic fluid neutrophil counts less than 250 cells/mm3 and signs and symptoms of infection should also receive empiric antibiotic therapy while awaiting results of cultures. | * Patients with ascitic fluid neutrophil counts less than 250 cells/mm3 and signs and symptoms of infection should also receive empiric antibiotic therapy while awaiting results of cultures. | ||
* When the ascitic fluid of a patient with cirrhosis is found to have a neutrophil count greater than or equal to 250 cells/mm3, and there is high suspicion of [[ | * When the ascitic fluid of a patient with cirrhosis is found to have a neutrophil count greater than or equal to 250 cells/mm3, and there is high suspicion of secondary [[peritonitis]], it should also be tested for total protein, [[lactic dehydrogenase]] (LDH), glucose, Gram's stain, [[carcinoembryonic antigen]], and [[alkaline phosphatase]] to assist with the distinction of SBP from secondary peritonitis. | ||
* Patients with ascitic fluid neutrophil counts greater than or equal to 250 cells/mm3 and clinical suspicion of SBP who also have a serum [[creatinine]] greater than 1 mg/dL, blood urea nitrogen greater than 30 mg/dL, or total [[bilirubin]] greater than 4 mg/dL should receive 1.5 g albumin per kg body weight within 6 hours of detection and 1.0 g/kg on day 3. | * Patients with ascitic fluid neutrophil counts greater than or equal to 250 cells/mm3 and clinical suspicion of SBP who also have a serum [[creatinine]] greater than 1 mg/dL, blood urea nitrogen greater than 30 mg/dL, or total [[bilirubin]] greater than 4 mg/dL should receive 1.5 g albumin per kg body weight within 6 hours of detection and 1.0 g/kg on day 3. | ||
==AASLD Recommendations for the Management of Spontaneous Bacterial Peritonitis== | |||
{{cquote| | |||
# Patients with ascites admitted to the hospital should undergo abdominal paracentesis. Paracentesis should be repeated in patients (whether in the hospital or not) who develop signs or symptoms or laboratory abnormalities suggestive of infection (e.g., abdominal pain or tenderness, fever, encephalopathy, renal failure, acidosis, or peripheral leukocytosis). | |||
# Patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm<sup>3</sup> in a community-acquired setting in the absence of recent beta-lactam antibiotic exposure should receive empiric antibiotic therapy, e.g., an intravenous third-generation cephalosporin, preferably cefotaxime 2 g every 8 hours. | |||
# Patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm<sup>3</sup> in a nosocomial setting and/or in the presence of recent beta-lactam antibiotic exposure should receive empiric antibiotic therapy based on local susceptibility testing of bacteria in patients with cirrhosis. | |||
# Oral ofloxacin (400 mg twice per day) can be considered a substitute for intravenous cefotaxime in inpatients without prior exposure to quinolones, vomiting, shock, grade II (or higher) hepatic encephalopathy, or serum creatinine greater than 3 mg/dL. | |||
# Patients with ascitic fluid PMN counts less than 250 cells/mm<sup>3</sup> and signs or symptoms of infection (temperature >100ºF or abdominal pain or tenderness) should also receive empiric antibiotic therapy, e.g., intravenous cefotaxime 2 g every 8 hours, while awaiting results of cultures. | |||
# When the ascitic fluid of a patient with cirrhosis is found to have a PMN count greater than or equal to 250 cells/mm<sup>3</sup> and there is high suspicion of secondary peritonitis, it should also be tested for protein, lactic dehydrogenase, glucose, Gram’s stain, carcinoembryonic antigen, and alkaline phosphatase to assist with the distinction of SBP from secondary peritonitis. Computed tomographic scanning should also be performed. | |||
# Patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm<sup>3</sup> in a nosocomial setting and/or in the presence of recent beta-lactam antibiotic exposure and/or culture an atypical organism(s) or have an atypical clinical response to treatment, should undergo a follow-up paracentesis after 48 hrs of treatment to assess the response in PMN count and culture. | |||
# Patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm<sup>3</sup> and clinical suspicion of SBP, who also have a serum creatinine >1 mg/dL, blood urea nitrogen >30 mg/dL, or total bilirubin >4 mg/dL should receive 1.5 g albumin per kg body weight within 6 hours of detection and 1.0 g/kg on day 3. | |||
}} | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
[[Category: | [[Category:Diseases involving the fasciae]] | ||
[[Category:Emergency medicine]] | |||
[[Category:Gastroenterology]] | |||
[[Category:Infectious disease]] | |||
[[Category:Inflammations]] |
Revision as of 21:18, 16 June 2014
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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], Chetan Lokhande, M.B.B.S [3], Guillermo Rodriguez Nava, M.D. [4], Alejandro Lemor, M.D. [5]
Overview
Empiric broad-spectrum intravenous antibiotic, preferably with a third generation cephalosporin such as cefotaxime, is warranted for suspected or established spontaneous bacterial peritonitis (SBP) to cover the most common isolates including Escherichia coli, Klebsiella pneumoniae, and Streptococcus pneumoniae. Oral ofloxacin may be considered in selected cases. Albumin should be reserved for patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 and clinical suspicion of SBP, who also have a serum creatinine >1 mg/dL, blood urea nitrogen >30 mg/dL, or total bilirubin >4 mg/dL.
Empiric Therapy Adapted from AASLD Practice Guidelines: Management of Adult Patients with Ascites Due to Cirrhosis.[1]
Spontaneous Bacterial Peritonitis |
---|
Preferred Regimen |
▸ Cefotaxime 2 g IV q8h (or 2 g IV q4h if life-threatening) OR ▸ Ticarcillin–Clavulanate 3.1 g IV q4–6h OR ▸ Piperacillin–Tazobactam 3.375 g IV q6h (or 4.5 g IV q8h) OR ▸ Ceftriaxone 1–2 g IV q12–24h OR ▸ Ertapenem 1 g IV q24h |
For ESBL–producing Enterobacteriaceae, check susceptibility testing. |
▸ Doripenem 500 mg IV q8h (1–hr infusion) OR ▸ Ertapenem 1 g IV q24h OR ▸ Imipenem–Cilastatin 0.5–1 g IV q6–8h OR ▸ Meropenem 1 g IV q8h OR ▸ Ciprofloxacin 400 mg IV q12h OR ▸ Levofloxacin 750 mg IV q24h OR ▸ Moxifloxacin 400 mg IV q24h |
- Empiric antibiotic therapy should be administered to patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 in a clinical setting compatible with ascitic fluid infection or those who have convincing signs or symptoms of infection (fever, abdominal pain, or unexplained encephalopathy) regardless of the PMN count in the ascitic fluid.[2][3]
- The 3 most common isolates from the ascitic fluid are Escherichia coli, Klebsiella pneumoniae, and Streptococcus pneumoniae.
- Relatively broad-spectrum therapy, preferably with cefotaxime, is warranted until the results of susceptibility testing are available.
- Infection with multiresistant organism including Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), and Enterococcus faecium is associated with an increased mortality. Risk factors for multiresistant infections include:[4]
- Nosocomial origin of infection
- Long-term norfloxacin prophylaxis
- Recent infection with multiresistant bacteria
- Recent use of beta-lactams
- Oral ofloxacin may be used alternatively in selected cases such as patients without vomiting, shock, grade II (or higher) hepatic encephalopathy, or serum creatinine greater than 3 mg/dL.[5]
Adjunctive Therapy
- Albumin infusion should be administered to cirrhotic patients with spontaneous bacterial peritonitis in the following conditions:[6]
- Serum creatinine> 1 mg/dL
- Blood urea nitrogen >30 mg/dL
- Total bilirubin >4 mg/dL
- Adjunctive intravenous albumin at a dose of 1.5 g/kg at the time of diagnosis, followed by 1 g/kg on day 3 is associated with a reduced incidence of renal impairment and death in comparison with treatment with an antibiotic alone.[7]
- The use of non-selective beta blockers in cirrhotic patients with SBP should be discouraged since it is associated with an increased risk for hemodynamic compromise, prolonged hospitalization, hepatorenal syndrome, acute kidney injury.[8]
Guidelines
- Patients with ascites admitted to the hospital should undergo abdominal paracentesis. Paracentesis should be repeated in patients who develop signs or symptoms or laboratory abnormalities suggestive of infection.[9]
- Oral ofloxacin can be considered a substitute for intravenous cefotaxime in inpatients without prior exposure to quinolones, vomiting, shock, grade II (or higher) hepatic encephalopathy, or serum creatinine greater than 3 mg/dL.
- Patients with ascitic fluid neutrophil counts less than 250 cells/mm3 and signs and symptoms of infection should also receive empiric antibiotic therapy while awaiting results of cultures.
- When the ascitic fluid of a patient with cirrhosis is found to have a neutrophil count greater than or equal to 250 cells/mm3, and there is high suspicion of secondary peritonitis, it should also be tested for total protein, lactic dehydrogenase (LDH), glucose, Gram's stain, carcinoembryonic antigen, and alkaline phosphatase to assist with the distinction of SBP from secondary peritonitis.
- Patients with ascitic fluid neutrophil counts greater than or equal to 250 cells/mm3 and clinical suspicion of SBP who also have a serum creatinine greater than 1 mg/dL, blood urea nitrogen greater than 30 mg/dL, or total bilirubin greater than 4 mg/dL should receive 1.5 g albumin per kg body weight within 6 hours of detection and 1.0 g/kg on day 3.
AASLD Recommendations for the Management of Spontaneous Bacterial Peritonitis
“ |
|
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References
- ↑ "Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012" (PDF).
- ↑ Runyon, Bruce A (2013-04). "Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012". Hepatology (Baltimore, Md.). 57 (4): 1651–1653. doi:10.1002/hep.26359. ISSN 1527-3350. PMID 23463403. Unknown parameter
|coauthors=
ignored (help); Check date values in:|date=
(help) - ↑ Hoefs, J C (1982-08). "Spontaneous bacterial peritonitis". Hepatology (Baltimore, Md.). 2 (4): 399–407. ISSN 0270-9139. PMID 7095741. Unknown parameter
|coauthors=
ignored (help); Check date values in:|date=
(help) - ↑ Fernández, Javier (2012-05). "Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study". Hepatology (Baltimore, Md.). 55 (5): 1551–1561. doi:10.1002/hep.25532. ISSN 1527-3350. PMID 22183941. Unknown parameter
|coauthors=
ignored (help); Check date values in:|date=
(help) - ↑ Navasa, M (1996-10). "Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis". Gastroenterology. 111 (4): 1011–1017. ISSN 0016-5085. PMID 8831596. Unknown parameter
|coauthors=
ignored (help); Check date values in:|date=
(help) - ↑ Sigal, Samuel H (2007-04). "Restricted use of albumin for spontaneous bacterial peritonitis". Gut. 56 (4): 597–599. doi:10.1136/gut.2006.113050. ISSN 0017-5749. PMC 1856861. PMID 17369392. Unknown parameter
|coauthors=
ignored (help); Check date values in:|date=
(help) - ↑ Sort, P (1999-08-05). "Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis". The New England journal of medicine. 341 (6): 403–409. doi:10.1056/NEJM199908053410603. ISSN 0028-4793. PMID 10432325. Unknown parameter
|coauthors=
ignored (help) - ↑ Mandorfer, Mattias (2014-06). "Nonselective β Blockers Increase Risk for Hepatorenal Syndrome and Death in Patients With Cirrhosis and Spontaneous Bacterial Peritonitis". Gastroenterology. 146 (7): 1680–1690.e1. doi:10.1053/j.gastro.2014.03.005. ISSN 1528-0012. PMID 24631577. Unknown parameter
|coauthors=
ignored (help); Check date values in:|date=
(help) - ↑ "National Guideline Clearinghouse | Management of adult patients with ascites due to cirrhosis: an update".