From the Guidelines
For spontaneous bacterial peritonitis (SBP) prophylaxis, norfloxacin 400 mg daily or trimethoprim-sulfamethoxazole (one double-strength tablet daily) are the preferred first-line options, as they have been shown to effectively reduce the risk of SBP in high-risk patients 1.
Key Points
- Ciprofloxacin 500 mg daily is an alternative option for SBP prophylaxis, although its use should be guided by local resistance patterns.
- Rifaximin (Xifaxan) is not recommended as primary prophylaxis for SBP, as studies have not consistently demonstrated its efficacy in preventing SBP compared to traditional antibiotics 1.
- Prophylaxis is indicated for patients with cirrhosis who have had a previous episode of SBP, those with low ascitic fluid protein (<1.5 g/dL) with impaired renal function or liver failure, and those with variceal bleeding.
- The goal of prophylaxis is to reduce gut bacterial translocation into the peritoneal cavity, which fluoroquinolones and trimethoprim-sulfamethoxazole accomplish effectively by targeting enteric gram-negative bacteria.
Patient Selection
- Patients who have recovered from an episode of SBP should be considered for long-term prophylaxis with norfloxacin or trimethoprim-sulfamethoxazole, as they are at high risk of recurrence 1.
- Patients with low ascitic fluid protein (<1.5 g/dL) and impaired renal function or liver failure should also be considered for primary prophylaxis.
- The use of proton pump inhibitors (PPIs) should be carefully assessed, as they may increase the risk of SBP development 1.
Treatment Duration
- Long-term prophylaxis should be continued indefinitely in patients with prior SBP or until liver transplantation in appropriate candidates.
- The decision to discontinue prophylaxis should be made on a case-by-case basis, taking into account the patient's individual risk factors and clinical status.
From the Research
Recommended Regimen for Spontaneous Bacterial Peritonitis (SBP) Prophylaxis
- The recommended regimen for SBP prophylaxis includes the use of antibiotics such as norfloxacin, ciprofloxacin, rifaximin, and trimethoprim-sulfamethoxazole 2, 3, 4, 5, 6.
- Norfloxacin has been the traditional choice for SBP prevention, but its use has raised concerns about antibiotic resistance 2, 4.
- Rifaximin has been suggested as an alternative to norfloxacin, with studies showing its efficacy in reducing the risk of SBP, particularly in secondary prophylaxis 2, 3, 5, 6.
Xifaxan (Rifaximin) as an Acceptable Option
- Rifaximin has been shown to be effective in reducing the risk of SBP, with a significant decrease in adverse events and mortality rate compared to norfloxacin 2, 3, 5, 6.
- A study found that rifaximin significantly reduced the odds for SBP development in secondary prophylaxis, with an odds ratio of 0.14 (95% CI 0.02-0.73, P = 0.02) 2.
- Rifaximin has been ranked as the highest in reducing the risk of SBP and death/transplant in a network meta-analysis 5.
- The use of rifaximin as an alternative to norfloxacin is supported by several studies, which suggest that it is a reasonable option for SBP prophylaxis 3, 6.
Comparison of Antibiotics for SBP Prophylaxis
- A systematic review and meta-analysis found that norfloxacin, ciprofloxacin, rifaximin, and trimethoprim-sulfamethoxazole were effective in reducing the risk of SBP, but rifaximin was ranked as the most effective 5.
- Another study found that once weekly ciprofloxacin was not inferior to once daily norfloxacin, with good tolerance and no induced resistance 6.
- Trimethoprim-sulfamethoxazole was associated with an increased risk of developing an adverse event, despite having similar efficacy to norfloxacin for primary and secondary prophylaxis of SBP 6.