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ofloxacin. However, the use of quinolones should not be considered in patients who are taken these drugs for prophylaxis against SBP, in areas where there is a high prevalence of quinoloneresistant bacteria or in nosocomial SBP (Level B1).

SBP resolves with antibiotic therapy in approximately 90% of patients. Resolution of SBP should be proven by demonstrating a decrease of ascitic neutrophil count to <250/mm3 and sterile cultures of ascitic fluid, if positive at diagnosis (Level A1). A second paracentesis after 48 hours of start of treatment may help guide the effect of antibiotic therapy.

Failure of antibiotic therapy should be suspected if there is worsening of clinical signs and symptoms and/or no marked reduction or increase in ascitic fluid neutrophil count compared to levels at diagnosis. Failure of antibiotic therapy is usually due to resistant bacteria or secondary bacterial peritonitis. Once secondary bacterial peritonitis has been excluded, antibiotics should be changed according to in vitro susceptibility of isolated organisms, or modified to alternative empiric broad spectrum agents (Level A1).

Spontaneous bacterial empyema should be managed similarly to than SBP.

Intravenous albumin in patients with spontaneous bacterial peritonitis without septic shock

SBP without septic shock may precipitate deterioration of circulatory function with severe hepatic insufficiency, hepatic encephalopathy, and type 1 hepatorenal syndrome (HRS) [121,126,127] and has approximately 20% hospital mortality despite infection resolution [121,126].

A randomized, controlled study in patients with SBP treated with cefotaxime showed that albumin (1.5 g/kg body weight at diagnosis, followed by 1 g/kg on day 3) significantly decreased the incidence of type 1 HRS (from 30% to 10%) and reduced mortality from 29% to 10% compared with cefotaxime alone. Treatment with albumin was particularly effective in patients with baseline serum bilirubin ≥68 µmol/L (4 mg/dl) or serum creatinine ≥88 µmol/L (1 mg/dl). It is unclear whether iv albumin is useful in patients with baseline bilirubin <68 µmol/L and creatinine <88 µmol/L, as the incidence of type 1 HRS was very low in the two treatment groups (7% without albumin and 0% with albumin) [121]. Nonrandomized studies in