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

Treatment of Spontaneous Bacterial Peritonitis (SBP)

Third-generation cephalosporins, particularly cefotaxime (2g IV every 8 hours for 5 days), are the first-line treatment for SBP and should be started immediately upon diagnosis without waiting for culture results. 1, 2

Initial Antibiotic Selection

First-line options:

• Cefotaxime: 2g IV every 8 hours for 5 days 1
  • Resolution rate: 77-98% of patients
  • 5-day therapy is as effective as 10-day treatment

Alternative regimens:

• Amoxicillin/clavulanic acid: 1/0.2g IV every 8 hours, followed by 0.5/0.125g PO every 8 hours 1

  • Similar efficacy to cefotaxime with potentially lower cost
  • Effective even in patients on norfloxacin prophylaxis

• Oral ofloxacin: 400mg PO twice daily 1, 3

  • Only for uncomplicated SBP (no renal failure, hepatic encephalopathy, GI bleeding, ileus, or shock)
  • Similar efficacy to IV cefotaxime in uncomplicated cases

• Ciprofloxacin: Initial IV therapy followed by oral step-down 1

  • Can be cost-effective compared to continuous IV cefotaxime

Special situations:

• Nosocomial SBP: Consider broader-spectrum antibiotics 4

  • Meropenem plus daptomycin has shown superior efficacy (86.7% vs 25%) compared to ceftazidime
  • Higher risk of resistant organisms

• Patients on quinolone prophylaxis: Avoid quinolones for treatment 1, 2

  • Use cefotaxime or amoxicillin/clavulanic acid instead

Adjunctive Therapy with Albumin

• Intravenous albumin should be administered to high-risk patients: 1, 2
  • Patients with serum bilirubin ≥4 mg/dL or serum creatinine ≥1 mg/dL
  • Dosing: 1.5 g/kg at diagnosis, followed by 1 g/kg on day 3
  • Significantly reduces incidence of type 1 hepatorenal syndrome (from 30% to 10%)
  • Reduces mortality from 29% to 10%

Monitoring Treatment Response

• Perform follow-up paracentesis after 48 hours of antibiotic therapy 1, 2
• Treatment failure should be suspected if:
  • Ascitic fluid neutrophil count fails to decrease by at least 25% of pre-treatment value
  • Clinical signs and symptoms worsen
  • No marked reduction in ascitic fluid neutrophil count

Treatment Failure Management

• If treatment fails, consider:
  • Resistant bacteria (especially in nosocomial SBP)
  • Secondary bacterial peritonitis
  • Change antibiotics based on culture and sensitivity results
  • If no culture results available, switch to broader-spectrum empiric coverage 1

Duration of Treatment

• Standard duration: 5-7 days 1, 2
• Resolution of SBP should be confirmed by:
  • Decrease of ascitic neutrophil count to <250/mm³
  • Sterile cultures of ascitic fluid (if initially positive)

Common Pitfalls and Caveats

1. Delayed treatment: Empiric antibiotics should be started immediately after diagnosis without waiting for culture results 1, 2

2. Inappropriate antibiotic selection: Avoid:

   • Nephrotoxic antibiotics (e.g., aminoglycosides)
   • Quinolones in patients already on quinolone prophylaxis
   • Inadequate coverage for nosocomial infections

3. Failure to administer albumin: Albumin significantly reduces mortality in high-risk patients 1

4. Inadequate monitoring: Follow-up paracentesis at 48 hours is essential to assess treatment response 1

5. Overlooking secondary peritonitis: Consider this diagnosis if treatment fails and obtain appropriate imaging (CT scan) 1

By following this evidence-based approach to SBP treatment, focusing on prompt administration of appropriate antibiotics and albumin in high-risk patients, mortality can be significantly reduced from historical rates of 30% to approximately 10% 5.