What is the step-by-step management plan for a patient with suspected spontaneous bacterial peritonitis (SBP)?

Step-by-Step Management Plan for Suspected Spontaneous Bacterial Peritonitis (SBP)

The management of suspected SBP requires immediate empirical antibiotic therapy with third-generation cephalosporins plus intravenous albumin, followed by a structured approach to monitoring and adjusting treatment based on clinical response. 1, 2

Step 1: Diagnosis

• Perform diagnostic paracentesis immediately in all cirrhotic patients with ascites at hospital admission, even without symptoms suggestive of infection 2
• Diagnostic paracentesis is also indicated in patients with:
  • Gastrointestinal bleeding
  • Shock or hemodynamic instability
  • Fever or other signs of systemic inflammation
  • Abdominal pain or gastrointestinal symptoms
  • Worsening liver and/or renal function
  • Hepatic encephalopathy 2
• Confirm SBP diagnosis with ascitic fluid polymorphonuclear (PMN) leukocyte count >250/mm³ 2
• Collect ascitic fluid for culture in aerobic and anaerobic blood culture bottles at bedside before starting antibiotics 2
• Obtain blood cultures before initiating antibiotics to identify potential bacteremia 1

Step 2: Immediate Treatment

• Start empirical antibiotics immediately upon diagnosis, without waiting for culture results 1, 2
• First-line antibiotic treatment:
  • Cefotaxime 2g IV every 6-8 hours for 5 days 3, 1
  • Alternative options for uncomplicated cases: amoxicillin-clavulanic acid (1g/0.2g IV every 8 hours) or ciprofloxacin (500mg every 12 hours) 4
  • For hospital-acquired SBP, consider broader coverage due to higher risk of resistant organisms 4
• Administer intravenous albumin:
  • 1.5 g/kg at diagnosis
  • 1 g/kg on day 3 1, 2
• This albumin therapy significantly reduces the risk of hepatorenal syndrome and mortality 1, 2

Step 3: Monitoring Treatment Response

• Perform a repeat paracentesis after 48 hours of treatment to assess response 1, 4
• Treatment success is indicated by:
  • Decrease in ascitic neutrophil count by at least 25% of pre-treatment value 3, 1
  • Improvement in clinical signs and symptoms 1
• If treatment fails (no reduction in neutrophil count or worsening symptoms), consider:
  • Resistant bacteria requiring antibiotic change based on culture results 3, 1
  • Secondary bacterial peritonitis requiring surgical evaluation 1

Step 4: Adjusting Treatment

• Modify antibiotics according to culture results and clinical response 4
• Complete a 5-day course of antibiotics if responding well (as effective as a 10-day treatment) 1
• For treatment failure with resistant organisms:
  • Change antibiotics according to in vitro susceptibility 3
  • Consider broader spectrum agents like carbapenems or piperacillin-tazobactam for hospital-acquired infections 5, 6

Step 5: Prevention of Recurrence

• For patients who recover from SBP, initiate secondary prophylaxis with:
  • Norfloxacin 400mg once daily, or
  • Ciprofloxacin 500mg once daily, or
  • Co-trimoxazole (800mg sulfamethoxazole/160mg trimethoprim daily) 4
• Continue prophylaxis indefinitely until liver transplantation or death 4

Special Considerations

• Patients with gastrointestinal bleeding should receive prophylactic antibiotics, with ceftriaxone as the preferred choice in severe liver disease 4
• For patients developing SBP while on quinolone prophylaxis, cefotaxime or amoxicillin/clavulanic acid are effective alternatives 3
• Delaying antibiotic therapy increases mortality, with a 10% increase for every hour's delay in cirrhotic patients with septic shock 2

Pitfalls and Caveats

• Increasing bacterial resistance is a significant concern, particularly for quinolones and in patients with previous antibiotic exposure 4
• Hospital-acquired SBP has higher mortality rates due to increased antibiotic resistance 4
• Quinolones should not be used in patients already taking these drugs for prophylaxis, in areas with high quinolone resistance, or in nosocomial SBP 3

Remember that SBP has approximately 20% hospital mortality rate despite infection resolution, but early appropriate antibiotic treatment combined with albumin therapy significantly improves survival 1, 2.