From the Guidelines
The treatment for spontaneous bacterial peritonitis (SBP) consists primarily of empiric antibiotic therapy with a third-generation cephalosporin, typically cefotaxime 2g IV every 8 hours or ceftriaxone 1-2g IV daily for 5-7 days, as recommended by the most recent guidelines 1. The choice of antibiotic should be guided by the local resistance profile and the severity of infection, with consideration of multidrug-resistant organisms 1. Alternative options include amoxicillin-clavulanate or fluoroquinolones like ciprofloxacin, especially in patients with penicillin allergies 1. Treatment should begin immediately after diagnostic paracentesis confirms SBP (ascitic fluid neutrophil count ≥250 cells/mm³) 1. In addition to antibiotics, albumin infusion (1.5 g/kg on day 1 and 1 g/kg on day 3) is recommended to prevent renal dysfunction and reduce mortality, particularly in high-risk patients with serum creatinine >1 mg/dL, BUN >30 mg/dL, or total bilirubin >4 mg/dL 1. Some key points to consider in the treatment of SBP include:
- The importance of early treatment with empiric antibiotics to improve outcomes 1
- The need to consider local resistance profiles and the severity of infection when choosing an antibiotic 1
- The use of albumin infusion to prevent renal dysfunction and reduce mortality 1
- The potential for multidrug-resistant organisms and the need for specialist microbiology input 1 After successful treatment, long-term antibiotic prophylaxis with norfloxacin 400 mg daily or trimethoprim-sulfamethoxazole is indicated for patients who have had previous episodes of SBP, as recurrence rates are high 1. The effectiveness of antibiotic therapy stems from targeting the most common causative organisms, which are typically gram-negative enteric bacteria (especially E. coli) and gram-positive cocci like Streptococcus species that have translocated from the intestinal lumen into the ascitic fluid in patients with advanced liver disease and compromised immune function 1.
From the Research
Treatment of Spontaneous Bacterial Peritonitis (SBP)
The treatment of 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 is a knowledge of appropriate antibiotic regimens and an understanding of the setting in which infection develops.
- 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 fluoroquinolone prophylaxis or for those with a penicillin allergy 3.
- Alternative antibiotics such as piperacillin-tazobactam should be considered for patients with nosocomial SBP or for patients who fail to improve on traditional antibiotic regimens 3.
- Broad-spectrum antibiotics have been recommended as empiric therapy for suspected SBP in areas/health care settings with high rates of multidrug-resistant (MDR) bacteria 4.
Adjunctive Therapy
Selective albumin supplementation remains an important adjunct in SBP treatment 3, 5.
- Albumin infusion is associated with reduced risk of renal impairment and mortality 5.
- 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
Efforts to prevent the development and recurrence of SBP with antibiotic prophylaxis are warranted 2.
- The most extensively studied form of prophylaxis involves selective intestinal decontamination (SID) with the oral fluoroquinolone norfloxacin 2.
- Prophylactic selective intestinal decontamination with oral norfloxacin is extremely useful in preventing SBP in patients that are at high risk for developing SBP 6.
- Individuals with low-protein ascites (ascitic fluid total protein < 1g/dL) benefit from SID with norfloxacin 400 mg daily during times of hospitalization 2.