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

Management of Spontaneous Bacterial Peritonitis

Immediate Empirical Antibiotic Therapy

Start third-generation cephalosporins immediately upon diagnosis without waiting for culture results, combined with intravenous albumin for patients with elevated bilirubin or creatinine. 1, 2

First-Line Antibiotic Regimen

• Cefotaxime 2g IV every 6-8 hours for 5 days is the recommended first-line treatment for community-acquired SBP 1, 2
• Alternative third-generation cephalosporins (e.g., ceftazidime) are equally effective 1
• A 5-day course is as effective as 10-day treatment, reducing unnecessary antibiotic exposure 2

Alternative Antibiotics

• Amoxicillin-clavulanic acid (1/0.2 g IV every 8 hours) is an acceptable alternative with comparable efficacy 1, 3
• Oral quinolones (ofloxacin 400mg every 12 hours or ciprofloxacin 500mg every 12 hours) can be used for uncomplicated cases 1
• Avoid quinolones in three specific situations: patients already on quinolone prophylaxis, areas with high quinolone resistance, or nosocomial SBP 1, 3

Nosocomial SBP Requires Broader Coverage

For nosocomial SBP, use meropenem 1g IV every 8 hours plus daptomycin 6mg/kg/day instead of third-generation cephalosporins due to high rates of resistant organisms 4

• This combination achieves 87% efficacy versus only 25% with ceftazidime in nosocomial cases 4
• Piperacillin-tazobactam is an alternative broad-spectrum option for nosocomial infections 5

Albumin Administration: Critical for Reducing Mortality

Administer IV albumin 1.5 g/kg at diagnosis, followed by 1 g/kg on day 3 to prevent hepatorenal syndrome and reduce mortality 1, 2, 3

Evidence for Albumin Benefit

• Albumin reduces mortality from 29% to 10% when combined with cefotaxime 1
• Reduces hepatorenal syndrome incidence from 30% to 10% 1
• Most beneficial in high-risk patients: bilirubin ≥4 mg/dL or creatinine ≥1 mg/dL 1
• Patients with bilirubin <4 mg/dL and creatinine <1 mg/dL have low HRS risk (7% without albumin), making albumin benefit less clear in this subgroup 1

Monitoring Treatment Response

Perform repeat paracentesis at 48 hours to assess treatment efficacy 1, 2, 3

Defining Treatment Success vs. Failure

• Success: Ascitic neutrophil count decreases by ≥25% from baseline or falls below 250/mm³ 1, 2, 3
• Failure: Neutrophil count fails to decrease by 25%, increases, or clinical deterioration occurs 1, 2, 3

Management of Treatment Failure

When treatment fails after 48 hours:

1. Exclude secondary bacterial peritonitis (perforated viscus) - look for multiple organisms on culture, very high protein (>1 g/dL), or surgical abdomen 1
2. Change antibiotics based on culture sensitivities if available 1
3. Broaden empirically to carbapenem or piperacillin-tazobactam if cultures pending 1, 6, 5
4. Consider resistant organisms, particularly if nosocomial acquisition 5, 4

Common Pitfalls to Avoid

Quinolone Use Errors

• Never use quinolones in patients already receiving them for SBP prophylaxis - resistance is nearly universal 1, 3
• Avoid in nosocomial SBP where gram-positive and resistant organisms predominate 1, 3, 5

Albumin Administration Errors

• Don't skip albumin in high-risk patients (bilirubin ≥4 mg/dL or creatinine ≥1 mg/dL) - this is where mortality benefit is proven 1
• Hydroxyethyl starch does NOT substitute for albumin and lacks circulatory benefits 1

Delayed Treatment

• Do not wait for culture results before starting antibiotics - every hour of delay increases mortality by 10% in septic patients 3
• Start empirical therapy immediately when ascitic neutrophil count >250/mm³ 1, 2, 3

Prognosis

• SBP carries approximately 20% hospital mortality despite infection resolution 1, 2, 3
• Early appropriate antibiotics plus albumin significantly improves survival 2, 3
• Treatment failure and development of acute kidney injury are independent predictors of 90-day mortality 4