What medication is recommended for the prevention of Spontaneous Bacterial Peritonitis (SBP)?

Norfloxacin is the Recommended Medication for Prevention of Spontaneous Bacterial Peritonitis (SBP)

Norfloxacin 400 mg daily is the most effective medication for prevention of Spontaneous Bacterial Peritonitis (SBP) in cirrhotic patients with ascites, particularly for those with prior SBP episodes or high-risk patients with low ascitic fluid protein. 1

Primary Prevention (No Prior SBP)

Primary prophylaxis should be considered in high-risk patients:

• Patients with severe liver disease (Child-Pugh score ≥9) with ascitic fluid protein <15 g/L and either:

  • Serum bilirubin ≥3 mg/dL OR
  • Impaired renal function (creatinine ≥1.2 mg/dL, BUN ≥25 mg/dL, or serum sodium ≤130 mEq/L) 1

• Patients with cirrhosis and acute upper gastrointestinal bleeding should receive short-term prophylaxis (5-7 days) with:

  • IV ceftriaxone (preferred) until bleeding resolves 1
  • Alternative: norfloxacin 400 mg twice daily for 7 days 1

Secondary Prevention (After SBP Episode)

• All patients who have recovered from an episode of SBP should receive long-term prophylaxis with norfloxacin 400 mg daily until liver transplantation or resolution of ascites 1
• Recurrence risk without prophylaxis is approximately 70% at 1 year 1
• Norfloxacin reduces SBP recurrence from 68% to 20% 1

Alternative Prophylactic Regimens

When norfloxacin is unavailable or contraindicated:

• Ciprofloxacin 500 mg daily is a reasonable alternative 1

  • Weekly ciprofloxacin (750 mg once weekly) may be as effective as daily norfloxacin with similar outcomes 2

• Trimethoprim-sulfamethoxazole has similar efficacy but higher risk of adverse events 3

• Rifaximin (550 mg twice daily) shows promising results for secondary prophylaxis with:

  • Lower SBP recurrence compared to norfloxacin (7% vs 39%) 4
  • Fewer episodes of hepatic encephalopathy 4
  • May be particularly useful where quinolone resistance is a concern 1

Efficacy and Outcomes

• Norfloxacin significantly improves 3-month survival (94% vs 62%) in high-risk patients 1
• Prophylaxis reduces SBP incidence from 61% to 7% in high-risk patients 1
• Antibiotic prophylaxis reduces the risk of hepatorenal syndrome development (28% vs 41%) 1

Important Considerations and Caveats

• Quinolone prophylaxis may lead to increased infections from gram-positive bacteria and quinolone-resistant organisms 1
• Restrict prophylactic antibiotics to patients with the greatest risk of SBP to minimize resistance development 1
• Consider discontinuing quinolone prophylaxis in patients who develop infection with quinolone-resistant bacteria 1
• All patients recovering from SBP should be evaluated for liver transplantation due to poor long-term survival (30-50% at 1 year) 1
• Third-generation cephalosporins are preferred for treatment of active SBP but are not typically used for long-term prophylaxis 1
• In patients with liver impairment, fluoroquinolones should be used with caution 5

Duration of Prophylaxis

• Secondary prophylaxis should be continued indefinitely until liver transplantation or resolution of ascites 1
• The optimal duration of primary prophylaxis has not been clearly established 1