What is the recommended treatment for Spontaneous Bacterial Peritonitis (SBP)?

From the Guidelines

The recommended treatment for Spontaneous Bacterial Peritonitis (SBP) is empiric antibiotic therapy with a third-generation cephalosporin, typically cefotaxime 2g intravenously every 8 hours, as it covers most causative organisms and has high ascitic fluid concentrations during therapy 1.

Key Considerations

• Treatment should begin immediately after diagnostic paracentesis confirms SBP (ascitic fluid neutrophil count ≥250 cells/mm³) 1.
• Albumin infusion (1.5 g/kg on day 1 and 1 g/kg on day 3) should be administered alongside antibiotics in patients with renal dysfunction or severe liver disease to prevent hepatorenal syndrome 1.
• Alternatives to cefotaxime include amoxicillin-clavulanic acid or fluoroquinolones like ciprofloxacin, particularly in patients with penicillin allergies 1.
• The choice of empirical antibiotic should consider the severity of infection, local resistance profile, and whether the infection is community-acquired or healthcare-associated 1.

Antibiotic Therapy

• Cefotaxime has been extensively investigated in patients with SBP and is effective in achieving infection resolution in 77-98% of patients 1.
• A 5-day therapy is as effective as a 10-day treatment, and a dose of 4 g/day is as effective as a dose of 8 g/day 1.
• Amoxicillin-clavulanic acid has similar results to cefotaxime in terms of SBP resolution and mortality, but with a lower cost 1.

Monitoring and Adjustments

• A second diagnostic tap should be considered at 48 hours from starting treatment to check the efficacy of antibiotic therapy in patients who have an apparently inadequate response 1.
• If ascitic fluid neutrophil count fails to decrease to less than 25% of the pre-treatment value, this should raise suspicion of antibiotic resistance or the presence of ‘secondary peritonitis’ 1.

From the Research

SBP Treatment Overview

• The treatment of Spontaneous Bacterial Peritonitis (SBP) involves the use of non-nephrotoxic broad-spectrum antibiotics expected to cover the typical bacterial flora associated with SBP 2.
• The key to successful treatment of SBP is a knowledge of appropriate antibiotic regimens and an understanding of the setting in which infection develops, particularly those individuals at high risk for infection 2.

Recommended Antibiotic Regimens

• The treatment of choice is cefotaxime 2 g given intravenously every 8 hours for a total of 5 days 2.
• Third-generation, broad-spectrum cephalosporins remain a good initial choice for SBP treatment 3.
• Levofloxacin is an acceptable alternative for patients not receiving long-term flouroquinolone prophylaxis or for those with a penicillin allergy 3.
• Alternative antibiotics such as pipercillin-tazobactam should be considered for patients with nosocomial SBP or for patients who fail to improve on traditional antibiotic regimens 3.

Adjunctive Therapy

• Selective albumin supplementation remains an important adjunct in SBP treatment 3.
• The simultaneous administration of intravenous albumin and antibiotics for SBP has been shown to result in the decreased development of azotemia and hospitalization-related mortality 2.

Prevention and Prophylaxis

• Efforts to prevent the development and recurrence of SBP with antibiotic prophylaxis are warranted, particularly in individuals with low-protein ascites (ascitic fluid total protein < 1g/dL) 2.
• Long-term primary prophylaxis during outpatient management of individuals awaiting liver transplantation with severe ascites and advanced liver failure should also be considered 2.
• Norfloxacin 400 mg daily is recommended for long-term antibiotic prophylaxis in patients with a history of SBP 2, 4.