From the Guidelines
Spontaneous bacterial peritonitis (SBP) prophylaxis is recommended for cirrhotic patients with specific risk factors, including those with ascites and low protein (<1.5 g/dL), impaired renal function, or poor liver function, as well as patients with acute gastrointestinal bleeding. The indications for SBP prophylaxis in cirrhotic patients can be broken down into primary and secondary prophylaxis.
- Primary prophylaxis should be given to patients with cirrhosis who have ascites with low protein (<1.5 g/dL) plus either impaired renal function (creatinine ≥1.2 mg/dL, BUN ≥25 mg/dL) or poor liver function (Child-Pugh score ≥9, bilirubin ≥3 mg/dL), as well as patients with acute gastrointestinal bleeding regardless of ascites presence 1.
- Secondary prophylaxis is indicated for all patients with a previous episode of SBP 1. The recommended medications for SBP prophylaxis include norfloxacin 400 mg daily, ciprofloxacin 500 mg daily, or trimethoprim-sulfamethoxazole (one double-strength tablet daily or five days per week) 1. For patients with acute gastrointestinal bleeding, ceftriaxone 1g IV daily for 7 days is preferred 1. Prophylaxis should be continued indefinitely until liver transplantation, resolution of ascites, or death. These recommendations are based on the high recurrence rate of SBP and the significant mortality reduction with prophylaxis, as supported by studies such as those published in Gut 1 and the Journal of Hepatology 1. The medications work by suppressing gut bacterial flora, particularly gram-negative organisms, which are the most common causative agents in SBP. It is essential to consider local resistance patterns and protocol when choosing an antibiotic for SBP prophylaxis 1.
From the Research
Indications for SBP Prophylaxis in Cirrhotic Patients
The following are indications for spontaneous bacterial peritonitis (SBP) prophylaxis in cirrhotic patients:
- Patients with a history of SBP, as they have a high risk of recurrence 2, 3, 4
- Patients with low ascitic fluid protein and at least one more risk factor, such as gastrointestinal bleeding or variceal hemorrhage 3, 4
- Patients with cirrhosis and ascites who are at high risk of developing SBP, such as those with poor liver synthetic function or admission for gastrointestinal hemorrhage 4
- Patients who have undergone diagnostic paracentesis and meet the criteria for SBP, such as an ascites neutrophil count greater than 250/mm3 4
Recommended Prophylactic Antibiotics
The following antibiotics are recommended for SBP prophylaxis in cirrhotic patients:
- Norfloxacin, which has been shown to be effective in preventing SBP in patients with cirrhosis and ascites 5, 3, 4
- Ciprofloxacin, which has been shown to be effective in preventing SBP in patients with cirrhosis and ascites 5, 6
- Rifaximin, which has been shown to be effective in preventing SBP in patients with cirrhosis and ascites, and may be considered as an alternative to norfloxacin or ciprofloxacin 5, 6
- Trimethoprim-sulfamethoxazole, which has been shown to be effective in preventing SBP in patients with cirrhosis and ascites, but may be associated with an increased risk of adverse events 5, 6
Duration of Prophylaxis
The duration of prophylaxis for SBP in cirrhotic patients is not well established, but the following are recommended: