Treatment of Spontaneous Bacterial Peritonitis After Resolution
After resolution of spontaneous bacterial peritonitis (SBP), patients should receive long-term antibiotic prophylaxis with oral ciprofloxacin 500 mg daily until liver transplantation or resolution of ascites to prevent recurrence. 1
Secondary Prophylaxis for SBP
Patients who have recovered from an episode of SBP are at very high risk for recurrence. The 1-year probability of developing recurrent SBP is significantly higher without prophylaxis:
- Without prophylaxis: 68% recurrence rate
- With prophylactic antibiotics: 20% recurrence rate 1
Recommended Prophylactic Regimens
First-line option:
- Oral ciprofloxacin 500 mg daily 1
Alternative options:
Duration of Prophylaxis
Prophylaxis should be continued indefinitely until:
- Liver transplantation is performed
- Complete resolution of ascites occurs 2
Special Considerations
Antibiotic Resistance
The effectiveness of quinolones may be reduced in patients with:
- Prior colonization with multi-drug resistant organisms (MDROs)
- Previous exposure to broad-spectrum antibiotics 1
In these cases, antibiotic selection should be guided by:
- Previous culture results
- Local resistance patterns
- Prior antibiotic exposure 3
Monitoring During Prophylaxis
- Regular clinical assessment for signs of recurrent infection
- Periodic paracentesis if symptoms develop
- Monitoring for adverse effects of long-term antibiotic use 3
Liver Transplantation Evaluation
Given the poor long-term prognosis after an episode of SBP, all survivors should be evaluated for liver transplantation, as SBP is a marker of advanced liver disease with poor prognosis 4.
Pitfalls and Caveats
Antibiotic resistance: The emergence of resistant organisms is a growing concern with long-term antibiotic use. Regular reassessment of prophylactic regimens may be necessary 1.
Norfloxacin: Although extensively studied, norfloxacin is no longer available in the US market since 2014 1.
Incomplete treatment: Failure to provide secondary prophylaxis after an episode of SBP significantly increases mortality risk due to the high recurrence rate 5.
Monitoring for hepatorenal syndrome: Patients who have had SBP remain at risk for hepatorenal syndrome and should have renal function monitored regularly 6.
By implementing appropriate secondary prophylaxis after resolution of SBP, the risk of recurrence can be significantly reduced, improving survival and quality of life for patients with cirrhosis and ascites.