What is the treatment for Spontaneous Bacterial Peritonitis (SBP)?

From the Guidelines

Spontaneous Bacterial Peritonitis (SBP) treatment should be initiated immediately with empirical antibiotic therapy, specifically third-generation cephalosporins such as cefotaxime, in patients with community-acquired SBP and low prevalence of drug resistance.

Key Considerations

• Cefotaxime is the most studied third-generation cephalosporin, with a high resolution rate of 77-98% 1, and is recommended at a dose of 2 g every 6-8 hours, or 4 g/day, for 5 to 10 days 1.
• Alternative antibiotics, such as amoxicillin-clavulanic acid, ciprofloxacin, and carbapenems, may be considered based on local resistance patterns, severity of infection, and patient-specific factors 1.
• Nosocomial SBP and healthcare-associated SBP require broader initial antibiotic therapy, such as carbapenems, due to the high prevalence of multidrug-resistant organisms (MDROs) 1.
• Antibiotic stewardship is crucial, with antibiotic coverage narrowed as soon as culture results are available and given for as short a time as possible 1.

Important Details

• Ascitic fluid culture with bedside inoculation of blood culture bottles should be performed to guide the choice of antibiotic treatment when SBP is suspected 1.
• Second diagnostic paracentesis at 48 hours from the start of treatment may be considered to check the efficacy of antibiotic therapy 1.
• Prophylactic antibiotic treatment should be considered for patients at high risk of developing SBP, such as those with gastrointestinal bleeding and underlying ascites due to cirrhosis 1.

From the Research

Treatment of Spontaneous Bacterial Peritonitis (SBP)

The treatment of SBP typically involves the use of broad-spectrum antibiotics, with the goal of covering the most common causative agents, including Gram-negative bacteria such as Escherichia coli, Klebsiella spp, and Streptococcus spp 2. The choice of antibiotic regimen may depend on the setting in which the infection develops, with community-acquired infections often treated with third-generation cephalosporins, while nosocomial infections may require broader coverage with carbapenems or piperacillin-tazobactam 3.

Antibiotic Regimens

Some common antibiotic regimens for SBP include:

• Cefotaxime 2 g given intravenously every 8 hours for a total of 5 days 2
• Third-generation cephalosporins, such as ceftriaxone, for community-acquired infections 3
• Carbapenems or piperacillin-tazobactam for nosocomial infections 3
• Levofloxacin as an alternative for patients not receiving long-term fluoroquinolone prophylaxis or for those with a penicillin allergy 4

Adjunctive Therapy

In addition to antibiotic therapy, some patients may benefit from adjunctive treatments, such as:

• Selective albumin supplementation to reduce the risk of azotemia and hospitalization-related mortality 2
• Withholding acid suppressive medication and discontinuing beta-adrenergic antagonist therapy in patients with end-stage liver disease and resistant ascites 4

Special Considerations

Some special considerations in the treatment of SBP include:

• The increasing trend of bacterial resistance in ESLD patients with SBP, which may require the use of broader-spectrum antibiotics or newer antibiotics, such as beta-lactam/beta-lactamase inhibitor combinations 5
• The importance of early diagnosis and treatment, as delayed therapy can lead to increased mortality 3
• The need for individualized treatment approaches, taking into account the patient's underlying liver disease, comorbidities, and potential contraindications to certain therapies 6, 4