Introduction: Historically, spontaneous bacterial peritonitis (SBP) has represented one of
the most frequent and relevant infectious complications of advanced liver disease, and this is still valid
today. Nevertheless, in recent years the role of fungi as causative pathogens of primary peritonitis
in patients with cirrhosis has become not negligible. Another issue is linked with the traditional distinction,
instrumental in therapeutic choice, between community-acquired and nosocomial forms, according
to the onset. Between these two categories, another one has been introduced: the so-called
Objective: To discuss the most controversial aspects in the management of SBP nowadays in the
light of best available evidence.
Methods: A review of recent literature through MEDLINE was performed.
Results: The difference between community-acquired and nosocomial infections is crucial to guide
empiric antibiotic therapy, since the site of acquisition impact on the likelihood of multidrug-resistant
bacteria as causative agents. Therefore, third-generation cephalosporins cannot be considered the
mainstay of treatment in each episode. Furthermore, the distinction between healthcare-associated
and nosocomial form seems very subtle, especially in areas wherein antimicrobial resistance is widespread,
warranting broad-spectrum antibiotic regimens for both. Finally, spontaneous fungal peritonitis
is a not common but actually underestimated entity, linked to high mortality. Especially in patients
with septic shock and/or failure of an aggressive antibiotic regimen, the empiric addition of an
antifungal agent might be considered.
Conclusion: Spontaneous bacterial peritonitis is one of the most important complications in patients
with cirrhosis. A proper empiric therapy is crucial to have a positive outcome. In this respect, a careful
assessment of risk factors for multidrug-resistant pathogens is crucial. Likewise important, mostly
in nosocomial cases, is not to overlook the probability of a fungal ascitic infection, namely a spontaneous