What is the management of Spontaneous Bacterial Peritonitis (SBP) with sepsis and shock?

Management of Spontaneous Bacterial Peritonitis with Sepsis and Shock

For SBP with septic shock, immediately initiate IV antibiotics within one hour, use empiric broad-spectrum coverage (third-generation cephalosporin for community-acquired or carbapenem plus daptomycin for nosocomial), and administer IV albumin (1.5 g/kg at diagnosis, then 1 g/kg on day 3) to reduce mortality and prevent hepatorenal syndrome. 1, 2, 3

Immediate Antibiotic Therapy

Community-Acquired SBP with Septic Shock

• Start cefotaxime 2g IV every 8 hours immediately upon diagnosis without waiting for culture results 1, 2, 4
• The Surviving Sepsis Campaign mandates antimicrobial administration within one hour of recognition for septic shock 1
• Cefotaxime achieves 77-98% infection resolution rates and is the first-line agent for community-acquired SBP 2, 5
• Alternative dosing of cefotaxime 2g IV every 12 hours is equally effective as every 6-8 hour dosing 5

Nosocomial or Healthcare-Associated SBP with Septic Shock

• Use meropenem 1g IV every 8 hours plus daptomycin 6 mg/kg/day for nosocomial SBP, particularly in ICU patients, recent hospitalizations, or settings with high multidrug-resistant organism (MDRO) prevalence 2, 6
• This combination is significantly more effective than ceftazidime (86.7% vs 25% resolution rate) for nosocomial SBP 6
• The 35% MDRO rate in nosocomial SBP necessitates broader initial coverage 2
• Piperacillin-tazobactam can be considered as an alternative in areas with low MDRO prevalence 7

Combination Therapy Considerations

• The Surviving Sepsis Campaign suggests empiric combination therapy (two antibiotics of different classes) for initial management of septic shock 1
• De-escalate combination therapy within 3-5 days once clinical improvement occurs or susceptibilities are known 1

Critical Adjunctive Therapy: IV Albumin

Albumin administration is essential and significantly improves outcomes in SBP with septic shock:

• Give 1.5 g/kg IV at diagnosis, followed by 1 g/kg on day 3 1, 2, 3
• This reduces hepatorenal syndrome incidence from 30% to 10% and mortality from 29% to 10% 1, 2
• Albumin is particularly critical in patients with baseline serum bilirubin ≥68 μmol/L (4 mg/dL) or creatinine ≥88 μmol/L (1 mg/dL) 1
• Albumin improves circulatory function in ways that crystalloids and hydroxyethyl starch cannot replicate 1

Septic Shock Management Principles

Hemodynamic Support

• Apply standard Surviving Sepsis Campaign guidelines for fluid resuscitation and vasopressor support alongside SBP-specific therapy 1
• Monitor for development of hepatorenal syndrome, which occurs in approximately 30% of SBP patients treated with antibiotics alone 1

Source Control

• While surgical source control is critical in secondary peritonitis, SBP is managed medically without surgical intervention 1
• Exclude secondary bacterial peritonitis if treatment fails, as this requires surgical evaluation 1, 3

Monitoring Treatment Response

Repeat Paracentesis at 48 Hours

• Perform diagnostic paracentesis 48 hours after initiating treatment to assess response 1, 2, 3
• Treatment success is defined as ascitic neutrophil count decreasing to <250/mm³ 1, 2
• Treatment failure is suspected if neutrophil count fails to decrease by at least 25% of pre-treatment value or if clinical signs worsen 1, 3

Managing Treatment Failure

• Failure occurs in approximately 10% of cases and suggests resistant bacteria or secondary peritonitis 1
• Change antibiotics according to culture sensitivities or broaden empirically to alternative agents 1, 2
• Consider secondary bacterial peritonitis requiring surgical evaluation if no improvement 1, 3

Treatment Duration and De-escalation

• Treat for 5-7 days for most cases of SBP 2, 5
• Five days of therapy is as effective as 10 days 2, 5
• The Surviving Sepsis Campaign recommends 7-10 days for most serious infections with septic shock 1
• Narrow antibiotic coverage once pathogen identification and sensitivities are established 1
• Perform daily assessment for de-escalation opportunities 1

Critical Pitfalls to Avoid

Never Delay Antibiotics

• Do not wait for culture results before initiating empirical therapy 2, 3
• The one-hour window for antibiotic administration in septic shock is non-negotiable 1

Avoid Nephrotoxic Agents

• Do not use aminoglycosides (e.g., tobramycin) due to nephrotoxicity risk in cirrhotic patients 2
• Cefotaxime was found superior to tobramycin-ampicillin combination in initial studies 5

Recognize Nosocomial vs Community-Acquired

• Avoid quinolones in patients already on quinolone prophylaxis, in areas with high quinolone resistance, or for nosocomial SBP 1
• The shift toward MDROs in nosocomial settings (35% rate) requires broader initial coverage than traditional third-generation cephalosporins 2, 6

Do Not Omit Albumin

• Albumin is not optional—it is a mortality-reducing intervention with Level A1 evidence 1, 2
• The 20% hospital mortality rate despite infection resolution underscores the importance of preventing hepatorenal syndrome 1, 8

Prognostic Factors

• Ineffective response to first-line treatment is an independent predictor of 90-day mortality (HR: 20.6) 6
• Development of acute kidney injury during hospitalization significantly worsens prognosis (HR: 23.2) 6
• Baseline mean arterial pressure is an independent predictor of 90-day transplant-free survival 6
• Despite 90% infection resolution rates, hospital mortality remains 20-30% due to underlying liver disease severity and complications 1, 8