What is the management of Spontaneous Bacterial Peritonitis (SBP)?

From the Guidelines

Management of spontaneous bacterial peritonitis (SBP) requires prompt antibiotic therapy with third-generation cephalosporins as first-line treatment, specifically cefotaxime 2g IV every 8 hours for 5 days, as recommended by the most recent guidelines 1. The choice of antibiotic should be guided by the local bacterial resistance profiles and the severity of infection. In settings where multi-drug resistant organisms (MDROs) are prevalent, broader antibiotic coverage may be necessary, such as carbapenems 1. In addition to antibiotics, albumin infusion (1.5 g/kg on day 1 and 1 g/kg on day 3) is recommended for patients with renal dysfunction or serum creatinine >1 mg/dL to prevent hepatorenal syndrome 1. Some key points to consider in the management of SBP include:

• Prompt initiation of empirical antibiotic therapy after diagnostic paracentesis confirms SBP (ascitic fluid neutrophil count >250 cells/mm³) 1
• Use of third-generation cephalosporins, such as cefotaxime, as first-line treatment 1
• Consideration of alternative antibiotics, such as ceftriaxone or ciprofloxacin, in cases where cephalosporins cannot be used 1
• Importance of albumin infusion in preventing hepatorenal syndrome in patients with renal dysfunction or serum creatinine >1 mg/dL 1
• Need for follow-up paracentesis after 48 hours of treatment to confirm response to therapy 1
• Essential role of secondary prophylaxis with norfloxacin or trimethoprim-sulfamethoxazole after recovery to prevent recurrence 1
• Addressing the underlying liver disease, as SBP indicates advanced cirrhosis with poor prognosis, often necessitating liver transplant evaluation 1

From the Research

SBP Management

• SBP is a common infection in patients with cirrhosis and ascites, associated with significant risk of mortality 2
• The typical presentation of SBP includes abdominal pain, worsening ascites, fever, or altered mental status in a patient with known liver disease 2
• Paracentesis is the diagnostic modality of choice and should be performed in any patient with ascites and concern for SBP or upper gastrointestinal bleeding 2, 3
• An ascites absolute neutrophil count (ANC) ≥ 250 cells/mm3 is diagnostic of SBP 2

Treatment

• Management traditionally includes a third-generation cephalosporin, but specific patient populations may require more broad-spectrum coverage with a carbapenem or piperacillin-tazobactam 2, 4, 5
• Albumin infusion is associated with reduced risk of renal impairment and mortality 2, 4, 5
• A short course (5 days) of ceftriaxone is useful therapy for SBP, with total resolution of SBP after prolonged therapy with ceftriaxone or another agent selected according to antibiotic susceptibility achieved in 94% of patients 6

Risk Factors

• Risk factors for developing SBP include advanced age, refractory ascites, variceal bleeding, renal failure, low albumin levels, bilirubin over 4 mg/dl, Child-Pugh class C, and a previous diagnosis of SBP 4
• Acid suppressive and beta-adrenergic antagonist therapies are strongly associated with SBP in at-risk individuals 5

Diagnosis

• Ultrasound should be used to optimize the paracentesis procedure 2
• Ascitic fluid should be placed in blood culture bottles to improve the culture yield 2
• Leukocyte esterase reagent strips can be used for rapid diagnosis if available 2