What is the diagnosis and treatment for Spontaneous Bacterial Peritonitis (SBP)?

From the Guidelines

Spontaneous bacterial peritonitis (SBP) should be treated with third-generation cephalosporins, specifically ceftriaxone 1-2g IV daily for 5-7 days, alongside albumin infusion (1.5g/kg on day 1, followed by 1g/kg on day 3) to reduce the risk of renal impairment and improve survival, as supported by the most recent and highest quality study 1.

Diagnosis and Treatment

• Diagnosis is made when the ascitic fluid neutrophil count exceeds 250 cells/mm³, typically confirmed by paracentesis.
• First-line treatment consists of third-generation cephalosporins, specifically ceftriaxone 1-2g IV daily for 5-7 days.
• Alternatives include cefotaxime 2g IV every 8 hours or, in patients with penicillin allergy, fluoroquinolones like ciprofloxacin 400mg IV twice daily.
• Albumin infusion (1.5g/kg on day 1, followed by 1g/kg on day 3) should be administered alongside antibiotics to reduce the risk of renal impairment and improve survival, as shown in a meta-analysis of 6 RCTs 1.

Prophylaxis and Management

• After recovery, long-term prophylaxis with norfloxacin 400mg daily or trimethoprim-sulfamethoxazole is recommended for patients who have had previous SBP, those with low protein ascites (<1.5g/dL), or advanced liver disease.
• SBP occurs when bacteria translocate from the intestines into the ascitic fluid, facilitated by increased intestinal permeability and impaired immune function in cirrhotic patients.
• The mortality rate remains high at 20-40%, making early recognition, treatment, and prophylaxis essential components of management, as highlighted in the EASL clinical practice guidelines 1.

Key Considerations

• The choice of antibiotics should be made taking into account the possibility of infection by quinolone-resistant strains, particularly in patients who have previously recovered from SBP and in those who have been exposed to quinolone 1.
• The use of albumin infusion has been shown to improve survival and reduce the incidence of renal impairment in patients with SBP, as demonstrated in a randomized controlled trial 1.

From the Research

Definition and Causes of Spontaneous Bacterial Peritonitis

• Spontaneous bacterial peritonitis (SBP) is an infection of the ascitic fluid in patients with advanced liver disease and ascites 2.
• The key to successful treatment of SBP is a knowledge of appropriate antibiotic regimens and an understanding of the setting in which infection develops, particularly those individuals at high risk for infection 2.
• SBP typically involves infection with a single organism, with Escherichia coli, Klebsiella spp, and Streptococcus spp responsible for nearly three fourths of cases 2.

Diagnosis and Treatment of Spontaneous Bacterial Peritonitis

• A high index of suspicion should lead to early diagnostic paracentesis and ascitic fluid analysis 2.
• Treatment of SBP involves the use of non-nephrotoxic broad-spectrum antibiotics expected to cover the typical bacterial flora associated with SBP 2.
• The treatment of choice is cefotaxime 2 g given intravenously every 8 hours for a total of 5 days 2.
• Other antibiotic regimens for SBP are less well studied, but ceftriaxone and ciprofloxacin have been shown to be effective in some studies 3, 4.

Prevention of Spontaneous Bacterial Peritonitis

• Efforts to prevent the development and recurrence of SBP with antibiotic prophylaxis are warranted, particularly in individuals with low-protein ascites or those awaiting liver transplantation 2.
• The most extensively studied form of prophylaxis involves selective intestinal decontamination (SID) with the oral fluoroquinolone norfloxacin 2.
• Patients with cirrhosis and upper gastrointestinal bleeding should receive norfloxacin 400 mg twice daily for 1 week following their bleed 2.

Complications and Mortality of Spontaneous Bacterial Peritonitis

• The infection-related mortality associated with SBP has decreased to less than 10%, but hospitalization-related mortality remains as high as 30% due to the severe underlying liver disease and the marked generation of cytokines and nitric oxide resulting from the infection 2.
• The simultaneous administration of intravenous albumin and antibiotics for SBP has been shown to result in the decreased development of azotemia and hospitalization-related mortality 5.