What is the duration of antibiotic therapy for Spontaneous Bacterial Peritonitis (SBP)?

From the Guidelines

The recommended duration of antibiotic treatment for spontaneous bacterial peritonitis (SBP) is typically 5 days, as a 5-day treatment group and a 10-day treatment group showed similar therapeutic effects 1. The standard regimen includes third-generation cephalosporins such as ceftriaxone (1-2g IV daily) or cefotaxime (2g IV every 8 hours). Some key points to consider when treating SBP include:

• Alternative options include amoxicillin-clavulanate or fluoroquinolones like ciprofloxacin, particularly in patients with penicillin allergies.
• Treatment can be guided by culture results when available, but empiric therapy should be started immediately upon diagnosis.
• Clinical improvement is usually seen within 48-72 hours, with resolution of fever and decreasing white cell count in the ascitic fluid.
• A repeat paracentesis to document response (neutrophil count <250 cells/mm³) is recommended after 48 hours if clinical improvement is not evident.
• For patients who have recovered from SBP, long-term antibiotic prophylaxis with norfloxacin (400mg daily) or trimethoprim-sulfamethoxazole is typically recommended to prevent recurrence, especially in patients awaiting liver transplantation.
• The short duration of treatment is generally sufficient because antibiotics achieve high concentrations in ascitic fluid, and prolonged courses may increase the risk of developing resistant organisms 1. Some studies have shown that:
• Cefotaxime at a dose of 2 g every 6-8 hours, or ceftriaxone at a dose of 1 g every 12-24 hours, are recommended by intravenous injection 1.
• Treatment with amoxicillin-clavulanic acid shows similar SBP resolution rates to cefotaxime, and treatment with ciprofloxacin 1. It's worth noting that the most recent and highest quality study, which is from 2018 1, recommends a treatment duration of 5 to 10 days, but the treatment duration should vary according to the symptoms and/or results of antimicrobial susceptibility testing.

From the Research

Duration of Antibiotics for SBP

• The duration of antibiotics for Spontaneous Bacterial Peritonitis (SBP) is typically 5 days, with cefotaxime 2 g given intravenously every 8 hours being the treatment of choice 2.
• A study published in 1995 found that a dose of 2 g every 8 h for 5 days was as effective as the same dose for 10 days 3.
• The antibiotic regimen is adjusted based on the results of ascitic fluid cultures, and other antibiotic regimens for SBP are less well studied 2.
• Third-generation, broad-spectrum cephalosporins remain a good initial choice for SBP treatment, and levofloxacin is an acceptable alternative for patients not receiving long-term fluoroquinolone prophylaxis or for those with a penicillin allergy 4.
• For uncomplicated SBP, early oral switch therapy is reasonable, and alternative antibiotics such as piperacillin-tazobactam should be considered for patients with nosocomial SBP or for patients who fail to improve on traditional antibiotic regimens 4, 5.

Factors Affecting Treatment Duration

• The development of hepatorenal syndrome, which complicates SBP in about 20% of cases, is a significant factor affecting treatment duration and outcome 5.
• Infusion of albumin significantly reduces the incidence of hepatorenal syndrome and consequently the risk of death 5.
• The emergence of multidrug-resistant agents as frequent causes of SBP, due to long-term quinolonic prophylaxis and increased antibiotic therapies, requires adjustment of the antibiotic regimen 5.
• The probability of positive cultures rapidly vanishes when they are performed during already implemented antibiotic administration, highlighting the importance of collecting blood, urine, and ascitic fluid for cultures before starting empirical antibiotic therapy 5.