Management of Spontaneous Bacterial Peritonitis with a Jackson-Pratt Drain
Critical First Step: Determine if This is True SBP or Secondary Peritonitis
The presence of a JP drain fundamentally changes the diagnosis—this is likely NOT spontaneous bacterial peritonitis but rather secondary bacterial peritonitis, which requires completely different management. 1
Diagnostic Differentiation
Perform abdominal CT immediately to identify any intra-abdominal source of infection (abscess, perforation, or drain-related complication). 1
Send ascitic fluid for additional tests beyond standard SBP workup: total protein, lactate dehydrogenase (LDH), glucose, carcinoembryonic antigen (CEA), and alkaline phosphatase to differentiate secondary from spontaneous peritonitis. 1
Secondary peritonitis characteristics that distinguish it from SBP include:
If Secondary Peritonitis is Confirmed
Remove the JP drain immediately as it is the likely source of infection and continued presence will prevent resolution.
Initiate broad-spectrum antibiotics covering polymicrobial flora: Use piperacillin-tazobactam or a carbapenem (meropenem 1g IV every 8 hours) PLUS metronidazole, NOT the third-generation cephalosporins used for SBP. 4, 5
Surgical consultation is mandatory to evaluate for need for source control, as secondary peritonitis may require operative intervention that antibiotics alone cannot resolve.
If True SBP is Confirmed (No Secondary Source Found)
Immediate Antibiotic Therapy
Start third-generation cephalosporins immediately—cefotaxime 2g IV every 8 hours or ceftriaxone 1-2g IV every 12-24 hours for 5-7 days. 1, 4, 6
For community-acquired SBP (infection present on admission or within 48 hours): Use cefotaxime or ceftriaxone as above. 1, 4
For hospital-acquired SBP (>48-72 hours after admission): Consider broader coverage with meropenem 1g IV every 8 hours plus daptomycin 6mg/kg/day due to 46-66% prevalence of ESBL-producing organisms and multidrug-resistant gram-positive bacteria in nosocomial cases. 1, 4
Mandatory Albumin Administration
Administer IV albumin 1.5 g/kg at diagnosis, then 1.0 g/kg on day 3—this reduces hepatorenal syndrome from 30% to 10% and mortality from 29% to 10%. 4, 6, 2
Monitoring Treatment Response
Repeat paracentesis at 48 hours to confirm ascitic neutrophil count has decreased to <25% of pre-treatment value. 4, 6
Treatment failure is defined as failure of neutrophil count to decrease adequately, which should prompt broadening antibiotic coverage and re-evaluation for secondary peritonitis. 4, 6
Adjust antibiotics based on culture results once available, narrowing spectrum when possible for antibiotic stewardship. 1, 4
Secondary Prophylaxis After Resolution
All patients surviving SBP require indefinite secondary prophylaxis with norfloxacin 400mg PO daily (or ciprofloxacin 500mg daily as alternative) until ascites resolves or liver transplantation occurs. 7, 4
Consider local quinolone resistance patterns when selecting prophylactic agent; co-trimoxazole 800/160mg daily is an alternative if quinolone resistance is high. 7
Critical Pitfalls to Avoid
Never assume SBP in the presence of surgical drains or recent abdominal procedures—always rule out secondary peritonitis first. 1
Never delay antibiotics waiting for culture results—empirical therapy must start immediately upon diagnosis. 4, 6
Never use aminoglycosides (such as tobramycin) due to nephrotoxicity in cirrhotic patients. 1, 4
Never forget albumin administration—it is not optional and provides mortality benefit independent of antibiotics. 4, 6, 2
Never use oral antibiotics as initial therapy in patients with drains, sepsis, or hemodynamic instability—IV therapy is mandatory. 4