What is the treatment plan for a patient with spontaneous bacterial peritonitis (SBP)?

Treatment Plan for Spontaneous Bacterial Peritonitis

The optimal treatment for spontaneous bacterial peritonitis (SBP) is intravenous cefotaxime 2g every 6-8 hours or ceftriaxone 1g every 12-24 hours for 5-10 days, combined with intravenous albumin (1.5 g/kg at diagnosis followed by 1 g/kg on day 3) to reduce mortality and prevent hepatorenal syndrome. 1

Initial Antibiotic Therapy

• Begin empirical antibiotic therapy immediately upon diagnosis of SBP, without waiting for culture results 1
• Third-generation cephalosporins are first-line treatment due to their excellent coverage of common causative organisms (primarily E. coli, Klebsiella, and Streptococcus) 1, 2
• Recommended regimens:
  • Cefotaxime: 2g IV every 6-8 hours (resolution rates 69-98%) 1, 3
  • Ceftriaxone: 1g IV every 12-24 hours (resolution rates 73-100%) 1, 2
• Standard treatment duration is 5-10 days, with 5 days being as effective as 10 days in most cases 1

Alternative Antibiotic Options

• Amoxicillin/clavulanic acid: 1g/0.2g IV every 8 hours, followed by 500mg/125mg PO every 8 hours 1
• Ciprofloxacin: 200mg IV every 12 hours for 7 days, or 200mg IV every 12 hours for 2 days followed by 500mg PO every 12 hours for 5 days 1, 3
• Oral ofloxacin (400mg every 12 hours) may be used in uncomplicated SBP without renal failure, hepatic encephalopathy, gastrointestinal bleeding, ileus, or shock 1
• Avoid quinolones in patients already taking them for prophylaxis or in areas with high quinolone resistance 1, 2
• Avoid potentially nephrotoxic antibiotics (e.g., aminoglycosides) 1, 4

Albumin Administration

• Administer intravenous albumin with antibiotics to prevent renal dysfunction and reduce mortality 1, 3
• Dosing: 1.5 g/kg body weight at diagnosis, followed by 1 g/kg on day 3 1, 3
• This intervention reduces the incidence of hepatorenal syndrome from 30% to 10% and mortality from 29% to 10% 3, 5

Monitoring Treatment Response

• Perform a second paracentesis after 48 hours of treatment to assess response 1, 2
• Treatment success is indicated by a decrease in ascitic fluid neutrophil count to <250/mm³ 1
• If neutrophil count fails to decrease by at least 25% after 48 hours, suspect treatment failure 1

Management of Treatment Failure

• Consider the following if treatment fails:
  • Resistant bacteria (adjust antibiotics based on culture and sensitivity results) 1, 2
  • Secondary bacterial peritonitis (perform CT scan to rule out) 1
• For hospital-acquired SBP or treatment failure, consider broader-spectrum antibiotics such as piperacillin-tazobactam or carbapenems 2, 6

Prophylaxis After SBP Episode

• All patients who survive an episode of SBP should receive indefinite antibiotic prophylaxis until liver transplantation or death 3, 2
• Norfloxacin 400mg daily is the most extensively studied regimen, reducing recurrence from 68% to 20% 3, 2
• Ciprofloxacin 500mg daily is an alternative prophylactic option 2, 4

Pitfalls and Caveats

• Increasing bacterial resistance, particularly to quinolones, is a growing concern 1, 2
• Hospital-acquired SBP has higher mortality rates and increased antibiotic resistance compared to community-acquired SBP 1, 6
• Patients on prophylactic quinolones who develop SBP may have quinolone-resistant organisms and require alternative empiric therapy 1, 7
• Secondary bacterial peritonitis should be considered if there is inadequate response to treatment (perform CT scan and check ascitic fluid for multiple organisms) 1