Editorial: Spontaneous Bacterial Peritonitis—Redrawing Empiric Therapy in the Era of Multidrug Resistance

In cirrhosis, spontaneous bacterial peritonitis (SBP) is a sentinel decompensating event with short-term mortality rates comparable to variceal haemorrhage [1]. However, three decades of reliance on empiric third-generation cephalosporins are being challenged by a shifting microbial landscape, particularly in South Asia, where multidrug-resistant organisms (MDRO) account for over 70% of infections [1, 2]. The multicenter SBP-INDIA study by Verma and colleagues provides essential data from this high-resistance environment, offering a clinically relevant framework for empiric therapy and stewardship [3]. The investigators analysed 319 hospitalized adults with culture-positive ascitic infections across 13 tertiary centers. MDRO and carbapenem-resistant organisms (CRO) were identified in 53.6% and 24.1%, respectively, with a predominance of gram-negative bacteria (74.6%) [3]. MDRO infection was independently associated with nosocomial or healthcare-associated acquisition, circulatory failure, and quinolone prophylaxis patterns broadly aligned with European cohorts but considerably greater in magnitude [4]. Crucially, 30-day survival was substantially lower with MDRO infection (53.2% vs. 73.6%), and resistance status remained an independent predictor of mortality, alongside organ failure and systemic inflammation [3]. Two findings deserve particular emphasis. First, the authors propose a risk-based empiric regimen tailored to acquisition setting and resistance phenotype (Table 1). This aligns with EASL and APASL recommendations [5, 6] but is now anchored in region-specific data. In environments where most nosocomial isolates are multidrug-resistant, cephalosporin monotherapy is no longer defensible. Broader coverage is required, followed by prompt de-escalation [7]. And second, the most provocative discovery is the outcome equivalence between SBP and non-neutrocytic bacterascites (NNBA). Nearly one-third of culture-positive patients presented with an ascitic neutrophil count (ANC) < 250 cells/mm3 yet faced mortality indistinguishable from classic SBP. This challenges the long-standing dichotomy that anchors treatment to the 250-cell threshold [5, 6, 8] and justifies a lower clinical threshold for intervention in symptomatic, culture-positive patients. Nonetheless, the increasing focus on microbiological data does not diminish the clinical relevance of ANC. Pleocytosis remains a vital prognostic indicator, as evidenced by the SBP vs. Culture-negative neutrocytic ascites (CNNA) comparison: CNNA demonstrated a significantly lower 90-day survival than SBP (38.9% vs. 61.1%, p = 0.003). This indicates that an elevated ANC represents a severe clinical state regardless of culture status. While the study's comparative design is insightful, a consolidated analysis simultaneously incorporating SBP, CNNA, and NNBA might have further elucidated the interplay between bacterial load and host inflammatory response. Though limited by its hospital-based, retrospective design and missing confounders, the consistency of the resistance signals and survival gaps renders these findings significant. Nevertheless, the recommendation to treat all NNBA cases requires a tempered interpretation; antibiotic therapy should ideally be guided by overt clinical signs of infection to avoid unnecessary broad-spectrum exposure in stable patients. Three practice priorities emerge: individualizing empiric antibiotic therapy by risk stratification rather than utilizing ANC cutoff alone. Antimicrobial stewardship must be intensified, especially in public-sector hospitals managing high-acuity cirrhosis. And novel agents, including cefiderocol and newer β-lactam/β-lactamase inhibitor combinations, urgently require evaluation in this population [9]. In conclusion, while SBP-INDIA necessitates a management re-evaluation of ascitic infections in an era of critical resistance, clinical policy must balance microbiological evidence with clinical judgement and stewardship to optimize survival. Apichat Kaewdech: conceptualization, writing – original draft. Pimsiri Sripongpun: conceptualization, writing – review and editing, supervision. The authors have nothing to report. This article is linked to Verma et al. papers. To view this article, visit https://doi.org/10.1111/apt.70716. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.