What is the management for a patient presenting with Spontaneous Bacterial Peritonitis (SBP)?

Management of Spontaneous Bacterial Peritonitis (SBP)

Immediate empirical antibiotic therapy must be initiated after diagnosis of SBP, with cefotaxime 2g IV every 8 hours for 5 days being the first-line treatment of choice. 1

Diagnosis

• Diagnostic paracentesis must be performed in all cirrhotic patients with ascites at hospital admission and in those with:

  • GI bleeding
  • Shock
  • Fever or other signs of systemic inflammation
  • GI symptoms
  • Worsening liver/renal function
  • Hepatic encephalopathy 1

• SBP is diagnosed when ascitic fluid neutrophil count is >250/mm³, regardless of culture results 1

• Both ascitic fluid and blood cultures should be collected before starting antibiotics to guide therapy, though positive culture is not required for diagnosis 1

Treatment Algorithm

First-line Antibiotic Therapy

• Cefotaxime 2g IV every 8 hours for 5 days 1, 2
  • 5-day therapy is as effective as 10-day treatment
  • Infection resolution rates of 77-98% 1
  • Provides high ascitic fluid concentrations and covers most causative organisms

Alternative Antibiotic Options

• For uncomplicated SBP (no renal failure, encephalopathy, GI bleeding, ileus, or shock):
  • Oral ofloxacin (comparable efficacy to IV cefotaxime) 1
  • Amoxicillin/clavulanic acid (IV then oral) 1
    • Caution: higher risk of drug-induced liver injury
  • Ciprofloxacin (IV or switch therapy) 1

Special Considerations

• Avoid nephrotoxic antibiotics (e.g., aminoglycosides) 1
• For healthcare-associated or nosocomial SBP:
  • Consider broader coverage (piperacillin-tazobactam or carbapenems) due to increasing multi-drug resistant organisms 1, 3, 4
• For patients on quinolone prophylaxis who develop SBP:
  • Cefotaxime or amoxicillin/clavulanic acid remain effective 1

Adjunctive Therapy

• Intravenous albumin administration reduces risk of renal impairment and mortality 2, 3

Monitoring Response

• If ascitic fluid neutrophil count fails to decrease to <25% of pre-treatment value after 2 days:
  • Consider treatment failure
  • Reassess antibiotic coverage
  • Rule out secondary bacterial peritonitis 1

Special Clinical Scenarios

Bacterascites (neutrophil count <250/mm³ with positive culture)

• If signs of systemic inflammation present: treat with antibiotics
• If asymptomatic: repeat paracentesis when culture results return
  • If repeat culture positive (regardless of neutrophil count): treat with antibiotics 1

Secondary Bacterial Peritonitis

• Suspect if:
  • Multiple organisms on culture
  • Very high neutrophil count
  • High ascitic protein concentration
  • Inadequate response to therapy
  • Localized abdominal symptoms/signs 1
• Management:
  • Prompt CT scan
  • Early surgical consultation 1

Prevention of Recurrence

• Long-term prophylaxis with norfloxacin 400mg daily for patients who have survived an episode of SBP 2, 5
• Consider liver transplant evaluation for all patients who develop SBP 4

Common Pitfalls to Avoid

• Delaying diagnostic paracentesis in patients with ascites and suspected infection 1, 3
• Using nephrotoxic antibiotics as empirical therapy 1
• Failing to collect cultures before starting antibiotics 1
• Not considering multi-drug resistant organisms in healthcare-associated or nosocomial SBP 1, 4
• Overlooking the possibility of secondary bacterial peritonitis in patients with inadequate response to therapy 1