Spontaneous bacterial peritonitis： The clinical challenge ofa leaky gut and a cirrhotic liver

Spontaneous bacterial peritonitis （SBP） is a frequent,life-threatening bacterial infection in patients withliver cirrhosis and ascites. Portal hypertension leadsto increased bacterial translocation from the intestine.Failure to eliminate invading pathogens due to immunedefects associated with advanced liver disease on thebackground of genetic predisposition may result in SBP.The efficacy of antibiotic treatment and prophylaxis hasdeclined due to the spread of multi-resistant bacteria.Patients with nosocomial SBP and with prior antibiotictreatment are at a particularly high risk for infectionwith resistant bacteria. Therefore, it is important toadapt empirical treatment to these risk factors and tothe local resistance profile. Rifaximin, an oral, nonabsorbableantibiotic, has been proposed to preventSBP, but may be useful only in a subset of patients.Since novel antibiotic classes are lacking, we have todevelop prophylactic strategies which do not inducebacterial resistance. Farnesoid X receptor agonistsmay be a candidate, but so far, clinical studies are notavailable. New diagnostic tests which can be carriedout quickly at the patient＇s site and provide additionalprognostic information would be helpful. Furthermore,we need tools to predict antibiotic resistance in orderto tailor first-line antibiotic treatment of spontaneousbacterial peritonitis to the individual patient and toreduce mortality.