What is the recommended treatment for spontaneous bacterial peritonitis?

From the Guidelines

The recommended treatment for spontaneous bacterial peritonitis (SBP) is immediate empiric antibiotic therapy with a third-generation cephalosporin, typically cefotaxime 2g intravenously every 8 hours or ceftriaxone 2g intravenously once daily for 5-7 days, as supported by the most recent and highest quality study 1. For patients with penicillin allergy, alternatives include fluoroquinolones such as ciprofloxacin 400mg intravenously twice daily. In addition to antibiotics, albumin infusion (1.5 g/kg on day 1 and 1 g/kg on day 3) is recommended for patients with renal dysfunction or severe liver disease to prevent hepatorenal syndrome, as shown in studies 1. Treatment should begin immediately after diagnostic paracentesis confirms SBP (ascitic fluid neutrophil count ≥250 cells/mm³). Repeat paracentesis after 48 hours of treatment is advised to confirm decreasing neutrophil counts. Following successful treatment, long-term antibiotic prophylaxis with norfloxacin 400mg daily or trimethoprim-sulfamethoxazole is recommended to prevent recurrence, particularly in patients awaiting liver transplantation, as suggested by guidelines 1. Prompt treatment is crucial as SBP carries high mortality if not treated quickly, with antibiotics targeting the most common causative organisms (Escherichia coli, Klebsiella, and Streptococcus). Key considerations in the management of SBP include:

• Early diagnosis and treatment to reduce mortality
• Use of third-generation cephalosporins as first-line antibiotic therapy
• Addition of albumin infusion in patients with renal dysfunction or severe liver disease
• Repeat paracentesis to confirm response to treatment
• Long-term antibiotic prophylaxis to prevent recurrence. It is essential to note that the landscape of bacterial resistance is continuously changing, and empirical antibiotic treatment should consider the severity of infection and local resistance profiles, as highlighted in recent guidelines 1.

From the FDA Drug Label

(8) Central nervous system infections, e.g., meningitis and ventriculitis, caused by Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, Klebsiella pneumoniae* and Escherichia coli*. Although many strains of enterococci (e.g., S. faecalis) and Pseudomonas species are resistant to cefotaxime sodium in vitro, Cefotaxime for Injection, USP has been used successfully in treating patients with infections caused by susceptible organisms.

The recommended treatment for spontaneous bacterial peritonitis is not directly mentioned in the provided drug label. However, cefotaxime can be used to treat infections caused by susceptible organisms.

• The drug label does mention the use of cefotaxime in treating various infections, including those caused by Escherichia coli and Klebsiella pneumoniae, which are common causes of spontaneous bacterial peritonitis.
• However, without direct information on the treatment of spontaneous bacterial peritonitis, caution should be exercised when using cefotaxime for this indication. 2

From the Research

Treatment for Spontaneous Bacterial Peritonitis

• The recommended treatment for spontaneous bacterial peritonitis (SBP) typically involves the use of broad-spectrum antibiotics, with third-generation cephalosporins being a common first-line choice 3, 4, 5.
• Studies have shown that third-generation cephalosporins, such as cefotaxime or ceftriaxone, are effective in treating SBP, with response rates ranging from 73% to 94% 4, 6.
• However, the use of carbapenems may be necessary in certain cases, such as in patients with multidrug-resistant organisms or those who are critically ill 3.
• The duration of antibiotic treatment for SBP is typically 5-7 days, but may need to be extended in some cases 4, 6.
• In addition to antibiotics, albumin supplementation has been shown to be beneficial in reducing mortality and improving outcomes in patients with SBP 4, 5.

Antibiotic Resistance and Treatment

• The increasing prevalence of antibiotic-resistant bacteria, including third-generation cephalosporin-resistant strains, is a concern in the treatment of SBP 7, 5.
• Studies have shown that the use of broad-spectrum antibiotics, such as carbapenems, may be necessary in cases where antibiotic resistance is suspected or confirmed 3, 7.
• The choice of antibiotic should be guided by local antimicrobial susceptibility patterns and the severity of the patient's illness 7, 5.

Prevention and Prophylaxis

• Primary prophylaxis with antibiotics, such as norfloxacin, may be considered in patients with cirrhosis and ascites who are at high risk of developing SBP 4, 5.
• Secondary prophylaxis with antibiotics may also be considered in patients who have had a previous episode of SBP 4, 5.
• Other measures, such as avoiding acid suppressive medication and discontinuing beta-adrenergic antagonist therapy, may also help reduce the risk of developing SBP 5.