From the Guidelines
The recommended initial antibiotic therapy for Spontaneous Bacterial Peritonitis (SBP) is a third-generation cephalosporin, specifically cefotaxime 2g intravenously every 8 hours or ceftriaxone 1-2g intravenously every 24 hours for 5-7 days. This recommendation is based on the most recent and highest quality study available, which prioritizes morbidity, mortality, and quality of life as the outcome 1.
Key Considerations
- The choice of antibiotics targets the most common causative organisms in SBP, which are primarily gram-negative enteric bacteria (especially Escherichia coli and Klebsiella) and gram-positive cocci like Streptococcus species.
- Treatment should be initiated immediately after diagnostic paracentesis without waiting for culture results if the ascitic fluid polymorphonuclear cell count exceeds 250 cells/mm³.
- Clinical improvement should be expected within 48 hours, and a follow-up paracentesis to document decreasing neutrophil count may be performed in patients who do not show clinical improvement.
- In patients with healthcare-associated SBP or recent antibiotic exposure, broader coverage with piperacillin-tazobactam or a carbapenem may be necessary due to potential resistant organisms.
Alternative Options
- For patients with penicillin allergy, alternatives include ciprofloxacin 400mg intravenously every 12 hours or levofloxacin 500mg intravenously once daily.
- Amoxicillin-clavulanic acid may also be considered as an alternative, as it has shown similar SBP resolution rates to cefotaxime 1.
Additional Recommendations
- Patients with SBP should be treated with IV albumin in addition to antibiotics (1.5 g/kg at day 1 and 1 g/kg at day 3) to reduce the risk of renal failure and improve outcomes 1.
- Non-selective beta blockers (NSBBs) should be temporarily held in patients with SBP who develop hypotension (mean arterial pressure <65 mm Hg) or AKI 1.
From the Research
SBP Treatment Overview
- The recommended initial antibiotic therapy for Spontaneous Bacterial Peritonitis (SBP) treatment is a crucial aspect of managing this life-threatening complication of liver cirrhosis.
- Third-generation cephalosporins have been considered the first-line treatment of SBP, as evident from studies such as 2 and 3.
Antibiotic Regimens
- A study published in 2016 4 compared meropenem plus daptomycin versus ceftazidime in the treatment of nosocomial SBP, finding the combination of meropenem plus daptomycin to be significantly more effective.
- Another study from 2021 5 evaluated whether carbapenems are superior to third-generation cephalosporins for treatment of SBP, concluding that empirical treatment with carbapenem does not reduce in-hospital mortality compared to treatment with third-generation cephalosporins, except in critically ill patients.
- The use of ciprofloxacin as an alternative, especially in switch therapy, has been explored 6, showing similar efficacy at lower cost compared to intravenous ceftazidime.
Treatment Considerations
- The choice of antibiotic regimen may depend on factors such as the presence of multidrug-resistant organisms, the severity of the patient's condition, and the risk of complications like renal failure.
- Studies like 3 highlight the importance of considering the bacteriology of SBP, with Gram-positive cocci and multi-resistant bacteria becoming more common, which may necessitate alternative antibiotic coverage.
- The role of adjunctive therapies, such as selective albumin supplementation and the management of underlying conditions like cirrhosis, is also crucial in the treatment of SBP.