What is the recommended treatment for spontaneous bacterial peritonitis?

Treatment of Spontaneous Bacterial Peritonitis

Third-generation cephalosporins, particularly cefotaxime 2g IV every 8 hours for 5-7 days, are the first-line treatment for spontaneous bacterial peritonitis (SBP), with intravenous albumin supplementation recommended for high-risk patients. 1, 2

First-Line Antibiotic Therapy

• Third-generation cephalosporins: The European Association for the Study of the Liver (EASL) recommends third-generation cephalosporins as first-line treatment 1

  • Cefotaxime 2g IV every 8 hours (most commonly used regimen)
  • Treatment duration: 5-7 days is typically sufficient 1, 3

• Alternative antibiotic options:

  • Amoxicillin/clavulanic acid: 1/0.2g IV every 8 hours, followed by 0.5/0.125g PO every 8 hours 1, 2
  • Ciprofloxacin: Only for uncomplicated SBP (no renal failure, hepatic encephalopathy, GI bleeding, ileus, or shock) 2, 4
    • Important caveat: Quinolones should be avoided in patients already on quinolone prophylaxis, in areas with high quinolone resistance, or in nosocomial SBP 1

Albumin Supplementation

• High-risk patients (serum bilirubin ≥4 mg/dL or serum creatinine ≥1 mg/dL) should receive IV albumin 1, 2:
  • 1.5 g/kg at diagnosis
  • 1 g/kg on day 3
  • This reduces the incidence of hepatorenal syndrome and decreases mortality from 29% to 10% 1

Monitoring Treatment Response

• Follow-up paracentesis should be performed after 48 hours of antibiotic therapy 1, 2
• Treatment success is defined as:
  • Decrease in ascitic fluid neutrophil count to <250/mm³
  • Decrease of at least 25% from pre-treatment value
  • Sterile cultures (if positive at diagnosis)
  • Clinical improvement 1

Treatment Failure Management

• Suspect treatment failure if:

  • No decrease in ascitic neutrophil count by at least 25% after 48 hours
  • Worsening clinical signs and symptoms
  • Persistent fever or worsening abdominal pain 1, 2

• Management of treatment failure:

  1. Rule out secondary bacterial peritonitis
  2. Adjust antibiotics based on culture results
  3. Consider broader spectrum antibiotics for resistant organisms 1

Special Considerations

• Resistant organisms: More common in:

  • Healthcare-associated or nosocomial SBP
  • Patients with recent antibiotic exposure
  • Patients on prophylactic antibiotics 2, 5

• Spontaneous bacterial empyema should be managed similarly to SBP 1

Common Pitfalls to Avoid

1. Delayed treatment initiation: Antibiotics should be started immediately after diagnosis 1
2. Inadequate dosing: Using 1g instead of 2g cefotaxime may lead to worse outcomes 6
3. Failing to administer albumin to high-risk patients (bilirubin ≥4 mg/dL or creatinine ≥1 mg/dL) 1
4. Not performing follow-up paracentesis to confirm treatment response 1, 2
5. Using quinolones in patients already on quinolone prophylaxis 1, 2
6. Missing secondary peritonitis: Consider this if treatment fails 1

Despite appropriate antibiotic therapy and resolution of infection, SBP still carries a high in-hospital mortality rate (approximately 20%) due to complications such as renal failure and hepatic decompensation 1, 3.