From the Guidelines
Norfloxacin 400 mg once a day is the recommended medication for secondary prophylaxis of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis who have had a previous episode of SBP, as it reduces the probability of recurrence of SBP from 68% to 20% 1. The choice of antibiotic for SBP prophylaxis is crucial in preventing recurrence and improving survival in patients with cirrhosis.
- The cumulative recurrence rate of SBP at 1 year is approximately 70% in patients who survive an episode of SBP 1.
- The probability of survival at 1 year after an episode of SBP is 30–50% and falls to 25–30% at 2 years 1.
- Norfloxacin has been shown to be effective in reducing the probability of recurrence of SBP, with a significant reduction in the probability of SBP due to Gram-negative bacteria (GNB) from 60% to 3% 1.
- Ciprofloxacin 500 mg once a day can be used as an alternative to norfloxacin, especially in areas where norfloxacin is not readily available 1.
- Regular monitoring for side effects and development of bacterial resistance is recommended during long-term prophylaxis.
- The use of proton pump inhibitors may increase the risk for the development of SBP, and indications for long-term use should be carefully assessed 1.
From the FDA Drug Label
For the prophylaxis in adults is 1 sulfamethoxazole and trimethoprim DS (double strength) tablet daily For children, the recommended dose is 750 mg/m2/day sulfamethoxazole with 150 mg/m2/day trimethoprim given orally in equally divided doses twice a day, on 3 consecutive days per week.
The recommended SBP prophylaxis drug is trimethoprim-sulfamethoxazole.
- For adults, the dosage is 1 DS tablet daily.
- For children, the dosage is 750 mg/m2/day sulfamethoxazole with 150 mg/m2/day trimethoprim, given orally in equally divided doses twice a day, on 3 consecutive days per week 2.
From the Research
Spontaneous Bacterial Peritonitis Prophylaxis Drugs
The following drugs are used for the prophylaxis of spontaneous bacterial peritonitis (SBP):
- Norfloxacin: a fluoroquinolone antibiotic that has been widely used for the prevention of SBP in patients with cirrhosis and ascites 3, 4, 5, 6, 7
- Ciprofloxacin: another fluoroquinolone antibiotic that has been shown to be effective in the prevention of SBP 3, 7
- Trimethoprim-sulfamethoxazole: a combination antibiotic that has been used as an alternative to norfloxacin for the prevention of SBP 3, 5, 7
- Rifaximin: a rifamycin antibiotic that has been shown to be effective in the prevention of SBP, particularly in patients with a history of SBP 3, 4, 7
Comparison of Prophylaxis Drugs
Studies have compared the efficacy of these drugs in the prevention of SBP:
- Norfloxacin and ciprofloxacin have been shown to be effective in the prevention of SBP, with similar efficacy 3
- Trimethoprim-sulfamethoxazole has been shown to be equally effective as norfloxacin in the prevention of SBP, but with a higher risk of adverse events 5
- Rifaximin has been shown to be more effective than norfloxacin in the prevention of SBP, particularly in patients with a history of SBP 4, 7
Recommendations
Based on the available evidence, the following recommendations can be made:
- Norfloxacin is a commonly used drug for the prevention of SBP, but rifaximin may be a better option for patients with a history of SBP 4, 7
- Ciprofloxacin and trimethoprim-sulfamethoxazole are alternative options for the prevention of SBP, but may have different efficacy and safety profiles compared to norfloxacin and rifaximin 3, 5, 7