What is the recommended prophylaxis for spontaneous bacterial peritonitis (SBP) in a patient with a history of hepatic cirrhosis admitted for gastrointestinal (GI) bleed following an endoscopy procedure?

SBP Prophylaxis in Cirrhotic Patients with GI Bleeding Post-Endoscopy

All cirrhotic patients with gastrointestinal bleeding should receive short-term antibiotic prophylaxis for 7 days, with intravenous ceftriaxone 1g daily being the preferred agent in patients with advanced cirrhosis (Child-Pugh B/C), while oral norfloxacin 400mg twice daily remains an acceptable alternative in less advanced disease or settings with low quinolone resistance. 1, 2

Rationale for Prophylaxis

Bacterial infections, including SBP, occur in 25-65% of cirrhotic patients with acute GI bleeding, with the highest incidence in those with advanced cirrhosis or severe hemorrhage. 1 The presence of bacterial infection is associated with:

• Increased failure to control bleeding 1
• Higher rebleeding rates 1
• Significantly increased hospital mortality 1

Antibiotic prophylaxis has been proven to reduce not only bacterial infections but also mortality and early rebleeding rates. 1 A meta-analysis demonstrated that prophylactic antibiotics significantly decreased the incidence of severe infections (SBP and/or septicemia) and overall mortality. 1

Antibiotic Selection Algorithm

First-Line: Intravenous Ceftriaxone

For patients with advanced cirrhosis (Child-Pugh B/C or at least 2 of: ascites, severe malnutrition, encephalopathy, or bilirubin >3 mg/dL), use ceftriaxone 1g IV every 24 hours for 7 days. 1, 3, 2

This recommendation is based on a landmark randomized controlled trial showing ceftriaxone was superior to norfloxacin in advanced cirrhosis, with significantly lower rates of:

• Proven or possible infections (11% vs 33%, P=0.003) 2
• Proven infections (11% vs 26%, P=0.03) 2
• SBP or spontaneous bacteremia (2% vs 12%, P=0.03) 2

Alternative: Oral Norfloxacin

For patients with less advanced cirrhosis (Child-Pugh A) or when IV access is problematic, norfloxacin 400mg orally twice daily for 7 days is acceptable. 1

Norfloxacin provides selective intestinal decontamination by targeting gram-negative bacteria while preserving anaerobic flora. 1 However, its efficacy has declined due to increasing quinolone resistance. 1, 2

Other Acceptable Alternatives

• Ciprofloxacin (oral or IV) with similar spectrum to norfloxacin 1
• Oral ofloxacin in uncomplicated patients without shock, renal dysfunction, or hepatic encephalopathy 1

Critical Considerations

Quinolone Resistance

The epidemiology of bacterial infections in cirrhosis has shifted, with increasing quinolone-resistant organisms. 1, 2 In the ceftriaxone vs norfloxacin trial, 6 of 7 gram-negative bacilli isolated in the norfloxacin group were quinolone-resistant. 2 Patients with prior quinolone exposure or previous SBP episodes are at particularly high risk for quinolone-resistant infections. 1

Timing and Duration

Initiate prophylactic antibiotics immediately upon admission with suspected variceal bleeding, even before diagnostic endoscopy. 1 The standard duration is 7 days maximum to minimize resistance development. 1

Local Resistance Patterns

Antibiotic selection should account for local antimicrobial susceptibility patterns. 1 In areas with high quinolone resistance (>30%), ceftriaxone should be strongly preferred. 1

Additional Management Considerations

Albumin Administration

While not specifically for infection prophylaxis, patients who develop SBP should receive IV albumin (1.5 g/kg at diagnosis, 1 g/kg on day 3) in addition to antibiotics, as this decreases hepatorenal syndrome and improves survival. 1, 3

Monitoring

• Assess for clinical improvement within 48-72 hours 3
• If no improvement, consider resistant organisms or alternative diagnoses 3
• Perform diagnostic paracentesis if new symptoms develop despite prophylaxis 3

Common Pitfalls to Avoid

1. Delaying antibiotic initiation until after endoscopy—start immediately upon admission 1
2. Using norfloxacin in advanced cirrhosis (Child-Pugh B/C) when ceftriaxone is superior 2
3. Extending prophylaxis beyond 7 days, which increases resistance risk without proven benefit 1
4. Ignoring local resistance patterns when selecting antibiotics 1
5. Assuming Child-Pugh A patients don't need prophylaxis—all cirrhotic patients with GI bleeding benefit from prophylaxis 1