The University of Toledo Translation Journal of Medical Sciences 
Internal Medicine Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e2 

Nosocomial vs Healthcare Associated vs 
Community Acquired SBP – A Systematic 
Review and Meta-Analysis 
Amna Iqbal1*, Azizullah Beran1, Sami Ghazaleh2, Yasmin Khader1, Kirubel 
Zerihun1, Sabeen Sidiki1, Wasef Sayeh1, Justin Chuang1, David Farrow1, Ziad 
Abuhelwa1, Sudheer Dhoop1, Jordan Burlen1, Muhammad Aziz2, Ragheb Assaly3, 
Mona Hassan2

1Division of Internal Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
2Division of Gastroenterology and Hepatology, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 
3Division of Pulmonary and Critical Care Medicine, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 

*Corresponding author: Amna.Iqbal@utoledo.edu

Published: 05 May 2023 

Introduction: Spontaneous bacterial peritonitis (SBP) is a common complication in decompensated 
liver cirrhosis. SBP is defined as ascitic fluid polymorphonuclear cell count > 250/mm3. Community 
acquired SBP (CA-SBP) occurs within 48 hours of admission to the hospital. Healthcare associated SBP 
(HA-SBP) is defined as SBP occurring in patients who were hospitalized in the preceding 90 days to 
months. Nosocomial SBP (N-NBP) occurs more than 48- 72 hours after hospital admission. 

Methods: We conducted a systematic review and meta-analysis on the studies that compared N-SBP, 
HA-SBP and CA-SBP. We performed a comprehensive database search in PubMed, Embase and Web of 
Science from inception through May 18, 2022. Randomized controlled trials, prospective and 
retrospective cohort studies and case series were included. Number of N-SBP, HA-SBP and CA-SBP 
episodes, ascitic fluid culture results and previous SBP episode data was gathered. The primary outcome 
was mortality rate in all types of SBP. The secondary outcome was resistance to third generation 
cephalosporins. The random effects model was used to calculate the risk ratios (RR), mean differences 
(MD) and confidence intervals (CI). A p value <0.05 was considered statistically significant. 
Heterogeneity was assessed using the Higgins I2 index.

Results: Fourteen retrospective and prospective cohort studies comprising a total of 2302 SBP episodes 
were included. The mortality rate was statistically significantly higher in N-SBP compared to HA-SBP 
(RR 1.84, p<0.0001, CI 1.43- 2.37, I2=0%) and CA-SBP (RR 1.69, p<0.00001, CI 1.4-1.98, I2= 33%), 
but not statistically significant between HA-SBP and CA-SBP (RR=1.40, p=0.34, CI=0.71-2.76, 
I2=53%). Resistance to third generation cephalosporins was statistically significantly higher in N-SBP 

https://dx.doi.org/10.46570/utjms.vol11-2023-700 

https://dx.doi.org/10.46570/utjms.vol11-2023-700
mailto:Amna.Iqbal@utoledo.edu


https://dx.doi.org/10.46570/utjms.vol11-2023-700 UTJMS 11(1):e1-e2 

https://dx.doi.org/10.46570/utjms.vol11-2023-700 2 ©2023 UTJMS 

compared to HA-SBP (RR=2.02, p=0.003, CI 1.26-3.22, I2=54%), CA-SBP (RR=3.96, p<0.00001, 
CI=2.50-3.60, I2=52%) and between HA-SBP and CA-SBP (RR=2.25,p=0.002, CI=1.33-3.81, I2=0%). 

Conclusion: A lower threshold to start broad spectrum antibiotics with targeted therapy guided through 
culture data should be undertaken for appropriate treatment of SBP and to improve mortality in N-SBP 
and HA-SBP. 

https://dx.doi.org/10.46570/utjms.vol11-2023-700
https://dx.doi.org/10.46570/utjms.vol11-2023-700