From the Guidelines
The treatment for spontaneous bacterial peritonitis (SBP) involves immediate empiric antibiotic therapy, typically with a third-generation cephalosporin such as ceftriaxone 1-2g IV daily for 5-7 days, as recommended by the most recent guidelines 1. Alternatives include cefotaxime 2g IV every 8 hours or, in patients with penicillin allergy, fluoroquinolones like ciprofloxacin 400mg IV twice daily. Antibiotic selection should be adjusted based on culture results when available. In addition to antibiotics, albumin infusion (1.5 g/kg on day 1 and 1 g/kg on day 3) is recommended for patients with renal dysfunction or severe liver disease to prevent hepatorenal syndrome, as supported by studies 1. After successful treatment, long-term prophylaxis with norfloxacin 400mg daily or trimethoprim-sulfamethoxazole one double-strength tablet daily is indicated for patients who have had a previous episode of SBP or those with low ascitic fluid protein levels (<1.5 g/dL). Some key points to consider in the management of SBP include:
- The importance of prompt initiation of empirical antibiotic therapy, given the high mortality associated with untreated SBP 1.
- The need to consider local resistance profiles and the severity of infection when selecting empirical antibiotics, due to the increasing prevalence of multidrug-resistant organisms 1.
- The role of albumin infusion in preventing hepatorenal syndrome in patients with SBP, particularly those with renal dysfunction or severe liver disease 1. Treatment should be initiated promptly upon diagnosis as SBP has high mortality if left untreated. The antibiotics work by targeting the common causative organisms, primarily gram-negative enteric bacteria that have translocated from the intestine into the ascitic fluid in patients with advanced liver disease and compromised immune function. It is also crucial to separate community-acquired SBP from healthcare-associated SBP and to consider both the severity of infection and the local resistance profile in order to decide the empirical antibiotic treatment of SBP 1.
From the Research
Treatment of Spontaneous Bacterial Peritonitis (SBP)
The treatment of SBP involves the use of non-nephrotoxic broad-spectrum antibiotics expected to cover the typical bacterial flora associated with SBP 2. The key to successful treatment is a knowledge of appropriate antibiotic regimens and an understanding of the setting in which infection develops.
Antibiotic Regimens
- Cefotaxime 2 g given intravenously every 8 hours for a total of 5 days is the treatment of choice 2, 3
- Other antibiotic regimens for SBP are less well studied, but broad-spectrum quinolones and third-generation cephalosporins have been considered effective 3, 4
- Piperacillin/tazobactam 4 g/0.5 g i.v. every 8 hours for 5 days can be used as empirical antibiotic therapy, with 20% human albumin administered at doses of 1.5 g/kg of patient weight on day 1 and 1.0 g/kg of patient weight on day 3 from the diagnosis 5
Adjunctive Therapy
- The simultaneous administration of intravenous albumin and antibiotics for SBP has been shown to result in the decreased development of azotemia and hospitalization-related mortality 2
- Albumin infusion based on body weight has been found to give the most favorable results compared to other regimens 6
Prevention of Recurrence
- Patients who have already had a previous episode of SBP can benefit from prophylactic treatment with norfloxacin 400 mg daily until the risk of SBP is removed by definitive resolution of the ascites or liver transplantation surgery 2, 4
- Cirrhotic patients with a high risk of SBP and other infections, such as those with gastrointestinal bleeding, can also benefit from primary prophylaxis with norfloxacin 4