From the Guidelines
The recommended treatment for enterococcus spontaneous bacterial peritonitis (SBP) should not be oral antibiotics as the first line of treatment, but rather intravenous antibiotics such as a third-generation cephalosporin or piperacillin-tazobactam, considering the high risk of morbidity and mortality associated with this condition. According to the most recent guidelines 1, the empirical antibiotic treatment of SBP depends on the severity of the infection and the local resistance profile. For community-acquired SBP, a third-generation cephalosporin or piperacillin-tazobactam is recommended, while for healthcare-associated or nosocomial SBP, the treatment should be tailored based on the prevalence of multi-drug resistant organisms (MDROs) and the severity of sepsis.
Some key points to consider in the treatment of SBP include:
- The use of potentially nephrotoxic antibiotics, such as aminoglycosides, should be avoided as empirical therapy 1.
- Cefotaxime, a third-generation cephalosporin, has been extensively investigated in patients with SBP and has shown high ascitic fluid concentrations during therapy, with infection resolution rates of 77-98% 1.
- Amoxicillin/clavulanic acid, given intravenously and then orally, has similar results to cefotaxime in terms of SBP resolution and mortality, but with a lower cost 1.
- Oral ofloxacin has shown similar results to intravenous cefotaxime in uncomplicated SBP, but its use should be considered in the context of local resistance profiles and the severity of the infection 1.
It is essential to note that enterococcal SBP is concerning due to its poor response to standard empiric SBP therapy, such as third-generation cephalosporins, which enterococci are intrinsically resistant to 1. Therefore, the treatment of enterococcus SBP should be tailored to the individual patient's needs, taking into account the severity of the infection, local resistance profiles, and the patient's underlying liver disease. After treatment, secondary prophylaxis with norfloxacin or trimethoprim-sulfamethoxazole should be considered to prevent recurrence, especially in patients with advanced cirrhosis or those awaiting liver transplantation 1.
From the Research
Treatment of Enterococcus SBP
- The recommended treatment for enterococcus spontaneous bacterial peritonitis (SBP) is a topic of discussion among clinicians, with some studies suggesting that empirical therapy with anti-enterococcal antibiotics may be necessary for patients with risk factors 2.
- Enterococcus SBP has been shown to have a poor prognosis, with a high mortality rate, especially when treated with inappropriate antibiotics such as third-generation cephalosporins 3.
- The use of oral antibiotics for the treatment of enterococcus SBP is not well-established, and most studies recommend the use of intravenous antibiotics such as ampicillin, vancomycin, or daptomycin 4, 5.
Antibiotic Resistance and Treatment
- Enterococci are often resistant to cephalosporins and aminoglycosides, making treatment challenging 3, 4.
- Vancomycin-resistant enterococci (VRE) are a significant concern, and alternative antibiotics such as linezolid, daptomycin, and tigecycline may be effective 4, 6.
- The combination of antibiotics may be necessary to achieve synergistic effects and overcome resistance, but the clinical choice of antibiotics should be guided by reasoned empiric therapy or targeted therapy based on microbiological results 6.
Clinical Outcomes and Risk Factors
- The outcome of enterococcus SBP is often poor, with a high mortality rate, especially in patients with nosocomial infections, previous use of antibiotics, and recent gastrointestinal endoscopy 3, 2.
- The use of amoxicillin as a documented therapy has been associated with a better outcome in patients with enterococcal bacteraemia 5.
- Clinicians should consider empirical therapy with anti-enterococcal antibiotics for patients with risk factors, such as nosocomial infection, previous use of antibiotics, and recent gastrointestinal endoscopy 2.