From the Guidelines
For empiric coverage of spontaneous bacterial peritonitis (SBP), I recommend starting with a third-generation cephalosporin such as ceftriaxone 2g IV once daily, as it is effective against the most common causative organisms, including gram-negative enteric bacteria like E. coli and Klebsiella, which are responsible for SBP due to bacterial translocation from the gut into the ascitic fluid in patients with cirrhosis and portal hypertension 1.
Alternatives and Special Considerations
Alternatives to ceftriaxone include cefotaxime 2g IV every 8 hours or, in patients with penicillin allergy, a fluoroquinolone like ciprofloxacin 400mg IV twice daily.
- Treatment should continue for 5-7 days, with adjustment based on culture results when available.
- For patients with risk factors for multidrug-resistant organisms (recent hospitalization, antibiotic use within 3 months, or healthcare-associated SBP), consider broader coverage with piperacillin-tazobactam 4.5g IV every 6 hours or meropenem 1g IV every 8 hours, as recommended by the American Association for the Study of Liver Diseases in 2021 1.
- Albumin administration (1.5g/kg on day 1, followed by 1g/kg on day 3) should be given to patients with renal dysfunction or severe liver disease to reduce the risk of hepatorenal syndrome, as supported by the most recent guidelines 1.
Long-term Prophylaxis
After successful treatment, long-term prophylaxis with norfloxacin 400mg daily or trimethoprim-sulfamethoxazole one double-strength tablet daily is recommended for patients with prior SBP episodes, to prevent recurrence and reduce the risk of further complications 1.
Monitoring and Adjustment
Response to empirical antibiotic therapy may be assessed by repeating diagnostic paracentesis/thoracentesis 2 days after initiation, and a decrease in fluid PMN <25% from baseline indicates lack of response and should lead to broadening of antibiotic coverage and further evaluation to rule out secondary bacterial peritonitis 1.
From the Research
SBP Empiric Coverage
- The empiric treatment of spontaneous bacterial peritonitis (SBP) typically involves the use of broad-spectrum antibiotics, with third-generation cephalosporins being a common choice 2, 3, 4.
- Cefotaxime is often considered the agent of choice for empiric therapy of SBP, with dosages ranging from 2 g every 6 hours to 2 g every 12 hours 2.
- However, the bacteriology of SBP is changing, with gram-positive cocci and multi-resistant bacteria becoming more common, which may require alternative antibiotic coverage 4, 5.
- For nosocomial SBP, a broader-spectrum antibiotic regimen such as meropenem plus daptomycin may be more effective than third-generation cephalosporins 5.
- Carbapenems may be considered as an alternative to third-generation cephalosporins for empirical treatment of SBP, particularly in critically ill patients with high chronic liver failure-sequential organ failure assessment (CLIF-SOFA) scores 6.
- The choice of empiric antibiotic coverage for SBP should be based on the individual patient's risk factors, underlying liver disease, and local antibiotic resistance patterns 3, 4, 6.
Antibiotic Regimens
- Cefotaxime 2 g every 8 hours for 5 days is a commonly recommended regimen for SBP 3.
- Alternative regimens include levofloxacin for patients not receiving long-term fluoroquinolone prophylaxis or for those with a penicillin allergy 4.
- Piperacillin-tazobactam may be considered for patients with nosocomial SBP or for those who fail to improve on traditional antibiotic regimens 4.
- Meropenem plus daptomycin may be considered for nosocomial SBP, particularly in patients with high-risk features or multi-resistant organisms 5.
- Carbapenems may be considered as an alternative to third-generation cephalosporins for empirical treatment of SBP, particularly in critically ill patients with high CLIF-SOFA scores 6.