From the Guidelines
Spontaneous bacterial peritonitis (SBP) should be treated with empirical antibiotic therapy, specifically IV third-generation cephalosporin, such as cefotaxime, as the first-line treatment.
Empirical Antibiotic Therapy
- The choice of empirical antibiotic therapy should be guided by the environment (nosocomial vs. community acquired), local bacterial resistance profiles, and severity of infection 1.
- In patients with community-acquired SBP, IV third-generation cephalosporin, such as cefotaxime, is recommended as the first-line treatment 1.
- In patients with healthcare-associated or nosocomial infection, or recent exposure to broad-spectrum antibiotics, empirical therapy with broad-spectrum antibiotics, such as carbapenems, should be initiated as the first line 1.
Dosing and Duration
- The dose of cefotaxime is 2 g every 8-12 hours, and the duration of treatment is typically 5-7 days 1.
- A 5-day therapy is as effective as a 10-day treatment 1.
Albumin Therapy
- IV albumin should be administered in addition to antibiotics, with a dose of 1.5 g/kg at day 1 and 1 g/kg at day 3, to reduce the incidence of type 1 hepatorenal syndrome (HRS) and mortality 1.
- Patients with acute kidney injury (AKI) and/or jaundice at the time of diagnosis of SBP are more likely to benefit from albumin therapy 1.
Monitoring and Adjustment
- Response to empirical antibiotic therapy should be assessed by repeating diagnostic paracentesis 2 days after initiation, and a decrease in fluid PMN <25% from baseline indicates lack of response and should lead to broadening of antibiotic coverage and further evaluation to rule out secondary bacterial peritonitis 1.
From the Research
Treatment of Spontaneous Bacterial Peritonitis (SBP)
The treatment of SBP typically involves the use of broad-spectrum antibiotics, with the selection of empirical antibiotic treatment guided by the severity and location of the infection, risk factors for multidrug-resistant organisms, and local expected bacteriology 2, 3, 4, 5, 6.
- The use of third-generation cephalosporins, such as cefotaxime, has been recommended as a first-line treatment for SBP 4, 6.
- Alternative antibiotics, such as levofloxacin, pipercillin-tazobactam, and newer antibiotics like cefiderocol, plazomicin, and eravacycline, may be considered for patients with nosocomial SBP or those who fail to improve on traditional antibiotic regimens 3, 4, 5.
- Selective albumin supplementation has been shown to be an important adjunct in SBP treatment, particularly in high-risk patients, and may help reduce the development of azotemia and hospitalization-related mortality 2, 6.
- The duration of antibiotic treatment is typically 5-7 days, but may be adjusted based on the results of ascitic fluid cultures and the patient's clinical response to treatment 4, 6.
Antibiotic Prophylaxis
Antibiotic prophylaxis has been shown to be effective in preventing SBP, particularly in high-risk patients, such as those with low-protein ascites or a history of SBP 4, 6.
- The use of norfloxacin, a fluoroquinolone antibiotic, has been recommended for primary prophylaxis in patients with cirrhosis and ascites, particularly during times of hospitalization or in patients awaiting liver transplantation 6.
- Secondary prophylaxis with norfloxacin may also be considered for patients who have survived an episode of SBP, until the risk of SBP is removed by definitive resolution of the ascites or liver transplantation surgery 6.