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

Treatment of Spontaneous Bacterial Peritonitis (SBP)

Third-generation cephalosporins, particularly cefotaxime (2g every 6-8 hours IV for 5-10 days), are the first-line treatment for spontaneous bacterial peritonitis in patients with cirrhosis due to their excellent coverage against Gram-negative bacteria and high ascitic fluid concentrations. 1, 2, 3

First-Line Antibiotic Options

• Cefotaxime (2g every 6-8 hours IV) has demonstrated infection resolution rates of 77-98% and should be initiated immediately after diagnosis 1, 2
• A 5-day therapy is as effective as a 10-day treatment for uncomplicated cases 1
• Ceftriaxone (1g every 12-24 hours IV) is an effective alternative with similar efficacy 2, 3
• Empirical antibiotic therapy must be started immediately after diagnosis, without waiting for ascitic fluid culture results 1

Alternative Antibiotic Options

• Amoxicillin/clavulanic acid (1/0.2g every 8h IV, followed by 0.5/0.125g every 8h PO) has shown similar efficacy to cefotaxime with potentially lower cost 1, 2
• Ciprofloxacin (200mg/12h IV for 7 days or 200mg/12h IV for 2 days followed by 500mg/12h PO for 5 days) is effective in uncomplicated SBP 1, 2
• Oral ofloxacin (400mg/12h) can be used in uncomplicated SBP without renal failure, hepatic encephalopathy, gastrointestinal bleeding, ileus, or shock 1
• Quinolones should be avoided in patients already taking these drugs for prophylaxis, in areas with high quinolone resistance, or in nosocomial SBP 1

Adjunctive Therapy with Albumin

• Intravenous albumin (1.5g/kg at diagnosis, followed by 1g/kg on day 3) significantly reduces:
  • Incidence of type 1 hepatorenal syndrome (from 30% to 10%)
  • Mortality (from 29% to 10%) 1, 2
• Albumin is particularly beneficial in patients with baseline serum bilirubin ≥4 mg/dl or serum creatinine ≥1 mg/dl 1
• Albumin improves circulatory function in SBP patients more effectively than other volume expanders 1

Monitoring Treatment Response

• A second paracentesis should be performed after 48 hours of treatment to assess efficacy 1, 2
• Resolution of SBP is confirmed by:
  • Decrease in ascitic neutrophil count to <250/mm³
  • Sterile cultures (if initially positive) 1, 2
• Treatment failure should be suspected if:
  • Clinical signs and symptoms worsen
  • No significant reduction in ascitic neutrophil count (should decrease to less than 25% of pre-treatment value) 1

Management of Treatment Failure

• Common causes of treatment failure include:
  • Resistant bacteria
  • Secondary bacterial peritonitis 1
• If treatment fails:
  • Exclude secondary bacterial peritonitis (consider CT scan)
  • Adjust antibiotics based on culture results and sensitivity
  • Consider broader-spectrum antibiotics empirically 1
• For nosocomial SBP, broader-spectrum antibiotics may be needed due to higher rates of resistant organisms 3, 4

Special Considerations

• Bacterascites (positive culture with neutrophil count <250/mm³):
  • Treat if patient shows signs of systemic inflammation/infection
  • Otherwise, repeat paracentesis when culture results return positive 1
• Spontaneous bacterial pleural empyema should be managed similarly to SBP 1
• In critically ill patients with high CLIF-SOFA scores (≥7), broader-spectrum antibiotics like carbapenems may be associated with lower mortality 5

Prophylaxis After SBP Episode

• Long-term, indefinite antibiotic prophylaxis is recommended for all patients who recover from SBP until liver transplantation or death 2, 3
• Norfloxacin 400mg daily is the most extensively studied regimen, reducing recurrence from 68% to 20% 2, 3
• Patients who survive an episode of SBP have a 70% risk of recurrence within one year without prophylaxis 3