From the Guidelines
For spontaneous bacterial peritonitis (SBP) prophylaxis in patients with cirrhosis, IV ceftriaxone is currently the recommended antibiotic in patients with hemorrhage, administered until hemorrhage has resolved and vasoactive drugs are discontinued, as it has been shown to be more effective than norfloxacin in preventing infections 1. In patients without gastrointestinal hemorrhage and without a prior episode of SBP, antibiotic prophylaxis may be considered in selected patients at a high risk of SBP, such as those with low ascitic fluid protein concentration, advanced liver disease, or renal dysfunction. Some key points to consider when deciding on SBP prophylaxis include:
- The risk of SBP and other bacterial infections is high in patients with cirrhosis and acute upper gastrointestinal hemorrhage 1
- The emergence of quinolone-resistant organisms has decreased the prophylactic efficacy of norfloxacin 1
- Norfloxacin was associated with a significantly reduced 1-year probability of first SBP compared with placebo in patients with low protein ascites and advanced liver failure or impaired renal function 1
- The incidence of hepatorenal syndrome (HRS) was also lower in patients randomized to norfloxacin 1 The use of norfloxacin 400 mg daily or other antibiotics such as ciprofloxacin 500 mg daily or trimethoprim-sulfamethoxazole (TMP-SMX) one double-strength tablet daily may be considered as alternatives, but IV ceftriaxone is the preferred choice in patients with hemorrhage 1. Regular monitoring for adverse effects and antibiotic resistance is important, and the duration of prophylaxis is typically indefinite or until liver transplantation, as the risk of recurrence remains high. In patients with variceal bleeding, short-term prophylaxis with ceftriaxone 1 g daily for 7 days is recommended regardless of ascites status, as it has been shown to reduce the rate of infections and improve survival 1.
From the Research
SBP Prophylaxis Drugs
The following drugs are used for SBP prophylaxis in patients:
- Norfloxacin: daily norfloxacin is effective as a prophylactic antibiotic for the prevention of spontaneous bacterial peritonitis in patients with cirrhosis 2
- Ciprofloxacin: once weekly ciprofloxacin was not inferior to once daily norfloxacin, with good tolerance and no induced resistance 2
- Trimethoprim-sulfamethoxazole: has similar efficacy for primary and secondary prophylaxis of spontaneous bacterial peritonitis, however, it was associated with an increased risk of developing an adverse event 2
- Rifaximin: was more effective than norfloxacin in the secondary prophylaxis of spontaneous bacterial peritonitis, with a significant decrease in adverse events and mortality rate 2
Patient Selection for Prophylaxis
Prophylaxis of spontaneous bacterial peritonitis is indicated in three high-risk populations:
- Patients with acute gastrointestinal hemorrhage 3
- Patients with low total protein content in ascitic fluid and advanced cirrhosis 3
- Patients with a previous history of spontaneous bacterial peritonitis (secondary prophylaxis) 3
Dosage and Duration
The dosage and duration of prophylaxis vary depending on the patient's condition and the specific drug used:
- Norfloxacin 400 mg daily during times of hospitalization for patients with low-protein ascites 4
- Norfloxacin 400 mg twice daily for 1 week following upper gastrointestinal bleeding 4
- Norfloxacin 400 mg daily until the risk of SBP is removed by definitive resolution of the ascites or liver transplantation surgery for patients who have survived an episode of SBP 4