Difficult to treat spontaneous bacterial peritonitis.

Spontaneous bacterial peritonitis (SBP) is the most frequent infection in patients with cirrhosis. It is associated with high mortality at admission and its occurrence alters the natural course with a high 1 year mortality. Presence of > 250 polymorphonuclear cell (PMN)/mm3 in the India ascitic fluid is diagnostic of SBP. SBP is usually treated with IV antibiotics using third generation cephalosporins and fluoroquinolones. However, despite effective initial treatment subsequent recurrence of SBP with its accompanying mortality has resulted in use of long term antibiotic prophylaxis and such patients are recommended for liver transplant. An increased frequency of multidrug resistant bacterial SBP has recently been recognised with use of prophylaxis and is associated with enhanced mortality. Further, cirrhotics get repeated hospitalisation and ICU care leading to nosocomial infection causing SBP. Therefore, frequency of multidrug resistant bacteria induced SBP among the above settings has increased and the relative risk (RR) of mortality with bacterial resistance has been estimated to be 4 times higher than in patients with SBP without bacterial resistance. Therapeutic approach in such patients at present is a clinical challenge and they are difficult to treat patients. Therefore, SBP can be categorized into community acquired and nosocomial! multidrug resistant SBP.