SBP Prophylaxis in Cirrhosis: Indications and Recommendations
SBP prophylaxis should be given to patients who have recovered from a previous episode of SBP, have low ascitic fluid protein (<10-15 g/L), or have advanced cirrhosis with gastrointestinal bleeding. 1
Indications for SBP Prophylaxis
Secondary Prophylaxis
- Patients who have recovered from one episode of SBP should receive prophylaxis with continuous oral norfloxacin 400 mg/day or ciprofloxacin 500 mg once daily 1
- This reduces the probability of SBP recurrence from approximately 70% to 20% and significantly improves survival 1, 2
- All patients with prior SBP should be considered for liver transplantation evaluation due to poor long-term survival (30-50% at one year) 1
Primary Prophylaxis
- Patients with low ascitic fluid protein concentration (<10-15 g/L) and advanced liver failure (Child-Pugh score ≥9 with serum bilirubin ≥3 mg/dl or impaired renal function) should receive prophylaxis 1
- Norfloxacin 400 mg daily significantly improves 3-month survival (94% vs 62%) and reduces SBP development (7% vs 61%) in high-risk patients 1
- The 2021 guidelines recommend prophylaxis for high-risk patients with ascitic protein <1.5 g/dL 1
Gastrointestinal Bleeding
- All cirrhotic patients with gastrointestinal bleeding should receive antibiotic prophylaxis to prevent SBP 1, 3
- For severe liver disease, IV ceftriaxone 1g daily for 7 days is recommended 1, 3
- For less severe liver disease, oral norfloxacin 400 mg twice daily or alternative oral quinolones for 7 days are appropriate 1, 3
Antibiotic Options and Considerations
First-Line Agents
- Norfloxacin 400 mg daily is the most extensively studied agent for SBP prophylaxis 1, 2
- Ciprofloxacin 500 mg daily is an acceptable alternative and commonly used in the UK 1
- Trimethoprim-sulfamethoxazole is effective but associated with more adverse events 1, 2
Emerging Options
- Rifaximin has shown promising results in secondary prophylaxis with fewer adverse events and lower mortality compared to norfloxacin 2
- Weekly ciprofloxacin may be as effective as daily norfloxacin with potentially less resistance development 2
Important Considerations and Pitfalls
Antibiotic Resistance
- Long-term quinolone prophylaxis can lead to increased gram-positive bacterial infections (79%) including MRSA 1
- Consider local bacterial resistance patterns when selecting prophylactic antibiotics 1, 4
- Unnecessary or prolonged antibiotic use increases risk of multidrug-resistant organisms 5
Monitoring and Follow-up
- Despite stable guideline recommendations since 2012, adherence to SBP prophylaxis guidelines remains low (55%) 6
- All patients with SBP should be considered for liver transplantation evaluation 1
- Regular monitoring for adverse effects of prophylactic antibiotics is essential 2, 4