What is the recommended treatment duration for Spontaneous Bacterial Peritonitis (SBP)?

From the Guidelines

The recommended treatment duration for Spontaneous Bacterial Peritonitis (SBP) is typically 5 days, as shown in a study by Runyon et al. 1, where cefotaxime 2g IV every 8 hours for 5 days resulted in a 93% resolution rate.

Treatment Overview

The standard regimen consists of third-generation cephalosporins, with cefotaxime 2g IV every 8 hours being the preferred first-line therapy, as supported by the study by Runyon et al. 1.

• Alternatives include ceftriaxone 1-2g IV daily or, in cases of penicillin allergy, fluoroquinolones such as ciprofloxacin 400mg IV twice daily.
• Treatment should begin immediately after diagnosis through paracentesis, without waiting for culture results, as recommended by the EASL clinical practice guidelines 1.
• Patients with renal dysfunction may require dose adjustments.
• Albumin administration (1.5 g/kg on day 1 and 1 g/kg on day 3) is recommended alongside antibiotics to reduce the risk of renal impairment and improve survival, particularly in high-risk patients with serum creatinine >1 mg/dL, BUN >30 mg/dL, or total bilirubin >4 mg/dL, as shown in a study by Sort et al. 1.

Key Considerations

• The relatively short treatment duration is sufficient because ascitic fluid antibiotic concentrations are high, and most cases respond quickly to appropriate therapy.
• Follow-up paracentesis to confirm resolution is generally not necessary unless symptoms persist.
• After successful treatment, long-term antibiotic prophylaxis with norfloxacin 400mg daily or trimethoprim-sulfamethoxazole is recommended to prevent recurrence in patients who have had an episode of SBP, as suggested by the EASL clinical practice guidelines 1.

Evidence Summary

The most recent and highest quality study, published in 2018 by the KASL clinical practice guidelines 1, recommends a treatment duration of 5 to 10 days, but the 2020 study by Anaesthesia 1 supports the use of a 5-day treatment duration, which is consistent with the findings of Runyon et al. 1.

• The use of third-generation cephalosporins, such as cefotaxime, is widely supported by the evidence, including studies by Runyon et al. 1 and the EASL clinical practice guidelines 1.
• The administration of albumin alongside antibiotics is also supported by the evidence, including a study by Sort et al. 1 and a meta-analysis published in Anaesthesia 1.

From the Research

Treatment Duration of SBP

The recommended treatment duration for Spontaneous Bacterial Peritonitis (SBP) is typically 5 days, with the use of non-nephrotoxic broad-spectrum antibiotics such as cefotaxime 2 g given intravenously every 8 hours 2.

• Key considerations:
  • The treatment regimen may be adjusted based on the results of ascitic fluid cultures.
  • The use of third-generation cephalosporins, such as cefotaxime, is considered the first-line treatment for SBP.
  • Alternative antibiotic regimens, such as meropenem plus daptomycin, may be considered for nosocomial SBP or for patients who fail to improve on traditional antibiotic regimens 3.
  • The treatment duration may vary depending on the severity of the infection and the patient's response to treatment.

Factors Influencing Treatment Duration

Several factors can influence the treatment duration of SBP, including:

• The severity of the infection
• The patient's underlying liver disease
• The presence of complications, such as renal failure
• The patient's response to treatment

Evidence-Based Recommendations

Studies have shown that a treatment duration of 5 days is effective in resolving SBP in most patients 4. However, some patients may require longer treatment durations, and the use of alternative antibiotic regimens may be necessary in certain cases 5, 6.

• Key recommendations:
  • Diagnostic paracentesis should be performed for every patient with cirrhosis, hospitalized with ascites.
  • Laboratory diagnosis of SBP should be carried out by polymorphonuclear count in the ascitic fluid, together with a positive culture from the ascitic fluid.
  • Antibiotics should be initiated promptly once the clinical and laboratory diagnosis of SBP has been made, before the result of ascitic fluid culture.