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World J Hepatol. Mar 27, 2015; 7(3): 304-314
Published online Mar 27, 2015. doi: 10.4254/wjh.v7.i3.304
Spontaneous bacterial peritonitis: The clinical challenge of a leaky gut and a cirrhotic liver
Philipp Lutz, Hans Dieter Nischalke, Christian P Strassburg, Ulrich Spengler
Philipp Lutz, Hans Dieter Nischalke, Christian P Strassburg, Ulrich Spengler, Department of Internal Medicine I, University of Bonn, D-53129 Bonn, Germany
Philipp Lutz, Christian P Strassburg, Ulrich Spengler, German Center for Infection Research, 38124 Braunschweig, Germany
Author contributions: Lutz P wrote the article; Nischalke HD, Strassburg CP and Spengler U critically revised the article.
Conflict-of-interest: No conflicts interest to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Dr. Philipp Lutz, Department of Internal Medicine I, University of Bonn, Sigmund-Freud-Strasse 25, D-53129 Bonn, Germany.
Telephone: +49-228-28715507 Fax: +49-228-28751419
Received: August 28, 2014
Peer-review started: August 29, 2014
First decision: November 14, 2014
Revised: November 30, 2014
Accepted: December 29, 2014
Article in press: December 31, 2014
Published online: March 27, 2015

Spontaneous bacterial peritonitis (SBP) is a frequent, life-threatening bacterial infection in patients with liver cirrhosis and ascites. Portal hypertension leads to increased bacterial translocation from the intestine. Failure to eliminate invading pathogens due to immune defects associated with advanced liver disease on the background of genetic predisposition may result in SBP. The efficacy of antibiotic treatment and prophylaxis has declined due to the spread of multi-resistant bacteria. Patients with nosocomial SBP and with prior antibiotic treatment are at a particularly high risk for infection with resistant bacteria. Therefore, it is important to adapt empirical treatment to these risk factors and to the local resistance profile. Rifaximin, an oral, non-absorbable antibiotic, has been proposed to prevent SBP, but may be useful only in a subset of patients. Since novel antibiotic classes are lacking, we have to develop prophylactic strategies which do not induce bacterial resistance. Farnesoid X receptor agonists may be a candidate, but so far, clinical studies are not available. New diagnostic tests which can be carried out quickly at the patient’s site and provide additional prognostic information would be helpful. Furthermore, we need tools to predict antibiotic resistance in order to tailor first-line antibiotic treatment of spontaneous bacterial peritonitis to the individual patient and to reduce mortality.

Keywords: Ascites, Cirrhosis, Farnesoid X receptor, Liver, Nucleotide-binding oligomerization domain containing 2, Rifaximin, Prophylaxis, Spontaneous bacterial peritonitis, Toll-like receptor 2

Core tip: Spontaneous bacterial peritonitis (SBP) is a frequent infection in patients with liver cirrhosis which is associated with a poor prognosis. Portal hypertension leads to translocation of intestinal bacteria which cannot be eliminated due to immune defects caused by liver cirrhosis and genetic predisposition. Empirical antibiotic treatment has become less effective because of wide-spread antibiotic resistance. This review summarises key features of SBP and points out how diagnosis, treatment and prophylaxis may be improved in the future in order to reduce mortality.