What is Spontaneous Bacterial Peritonitis (SBP) prophylaxis?

From the Guidelines

SBP prophylaxis should be given to cirrhotic patients with a previous episode of SBP or low ascitic fluid protein (<1.5 g/dL) with advanced liver disease or renal dysfunction, using norfloxacin 400 mg orally once daily, or ciprofloxacin 500 mg orally once daily, or trimethoprim-sulfamethoxazole (TMP-SMX) 1 double-strength tablet orally once daily, as recommended by the most recent guidelines 1. The recommended prophylaxis regimen is based on the latest evidence from the guidelines on the management of ascites in cirrhosis, which suggests that primary prophylaxis should be offered to patients considered at high risk, as defined by an ascitic protein count <1.5 g/dL 1.

Key Points

• Prophylaxis should be given to cirrhotic patients with:
  • A previous episode of SBP
  • Low ascitic fluid protein (<1.5 g/dL) with advanced liver disease or renal dysfunction
• The recommended prophylaxis regimen is:
  • Norfloxacin 400 mg orally once daily
  • Ciprofloxacin 500 mg orally once daily
  • Trimethoprim-sulfamethoxazole (TMP-SMX) 1 double-strength tablet orally once daily
• Duration of prophylaxis is typically long-term or until liver transplantation, as the risk of SBP recurrence is high, as supported by the guidelines 1 and other studies 1. This preventive approach is crucial because SBP is a severe complication with high mortality, and the antibiotics work by reducing bacterial translocation from the gut to the ascitic fluid, as explained in the guidelines 1 and other studies 1.

Monitoring and Side Effects

• Patients should be monitored for antibiotic resistance and potential side effects
• Regular liver function tests and renal function monitoring are advisable during long-term prophylaxis, as recommended by the guidelines 1 and other studies 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim oral suspension and other antibacterial drugs, sulfamethoxazole and trimethoprim oral suspension should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria Pneumocystis jirovecii Pneumonia For the treatment of documented Pneumocystis jirovecii pneumonia and for prophylaxis against P jirovecii pneumonia in individuals who are immunosuppressed and considered to be at an increased risk of developing P. jirovecii pneumonia.

Spontaneous Bacterial Peritonitis (SBP) prophylaxis is not mentioned in the provided drug labels. The FDA drug label does not answer the question.

From the Research

Definition and Purpose of Spontaneous Bacterial Peritonitis (SBP) Prophylaxis

• SBP prophylaxis refers to the use of antibiotic therapy to prevent the development of spontaneous bacterial peritonitis in patients with cirrhosis and ascites 2, 3, 4, 5, 6.
• The primary goal of SBP prophylaxis is to reduce the risk of developing SBP, which is a potentially life-threatening infection in patients with liver cirrhosis and ascites 3, 4.

Indications for SBP Prophylaxis

• Patients with a history of SBP are at high risk for developing recurrent SBP and should receive long-term antibiotic prophylaxis 2, 4, 5.
• Patients with cirrhosis and ascites who have a low ascitic fluid protein level (≤ 1 g/dl) and at least one other risk factor, such as gastrointestinal bleeding, renal failure, or low albumin levels, may also benefit from primary prophylaxis 5, 6.
• Other risk factors for developing SBP include advanced age, refractory ascites, variceal bleeding, and high bilirubin levels 3.

Antibiotic Regimens for SBP Prophylaxis

• Norfloxacin is a commonly used antibiotic for SBP prophylaxis, and studies have shown it to be effective in reducing the risk of SBP 2, 4, 6.
• Other antibiotics, such as ciprofloxacin, rifaximin, and trimethoprim-sulfamethoxazole, have also been shown to be effective in preventing SBP 2, 4.
• The choice of antibiotic regimen should be based on the individual patient's risk factors and medical history, as well as the potential for antibiotic resistance 3, 4.

Importance of Adherence to Guidelines

• Adherence to guidelines for SBP prophylaxis is crucial to prevent unnecessary cases of SBP and reduce mortality rates 5.
• Studies have shown that many cases of SBP could be prevented by adhering to guidelines, and that gastrointestinal bleeding is the most frequently overlooked indication for SBP prophylaxis 5.