From the Guidelines
Spontaneous bacterial peritonitis (SBP) prophylaxis is recommended for cirrhotic patients with ascites who have had a previous episode of SBP, have low ascitic fluid protein (<1.5 g/dL) with advanced liver disease or renal dysfunction, or are hospitalized with gastrointestinal bleeding. The most recent and highest quality study, 1, provides guidance on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome.
Key Indications for SBP Prophylaxis
- Previous episode of SBP
- Low ascitic fluid protein (<1.5 g/dL) with advanced liver disease or renal dysfunction
- Hospitalization with gastrointestinal bleeding
Recommended Prophylactic Medications
- Norfloxacin 400 mg daily
- Ciprofloxacin 500 mg daily
- Trimethoprim-sulfamethoxazole (one double-strength tablet daily)
- Ceftriaxone 1 g daily for 7 days for patients with gastrointestinal bleeding
Important Considerations
- Long-term prophylaxis should continue indefinitely for patients with prior SBP and until resolution of ascites or liver transplantation for other indications
- Patients on prophylaxis should be monitored for adverse effects including antibiotic resistance, Clostridium difficile infection, and drug-specific side effects
- Regular assessment of prophylaxis necessity is important, especially in patients whose liver function improves or who undergo liver transplantation As noted in 1 and 1, primary prophylaxis should be offered to patients considered at high risk, as defined by an ascitic protein count <1.5 g/dL. However, the potential risks and benefits and existing uncertainties should be communicated to patients. In addition, 1 emphasizes the importance of diagnostic paracentesis and ascitic fluid culture in guiding the choice of antibiotic treatment when SBP is suspected. Overall, the management of SBP prophylaxis should be individualized and based on the latest evidence and guidelines, such as those provided in 1.
From the Research
Indications for SBP Prophylaxis
The following are indications for spontaneous bacterial peritonitis (SBP) prophylaxis:
- Patients with cirrhosis and upper gastrointestinal bleeding should receive norfloxacin 400 mg twice daily for 1 week following their bleed 2
- Individuals with low-protein ascites (ascitic fluid total protein < 1g/dL) benefit from selective intestinal decontamination (SID) with norfloxacin 400 mg daily during times of hospitalization 2
- Long-term primary prophylaxis during outpatient management of individuals awaiting liver transplantation with severe ascites and advanced liver failure should also be considered 2
- Patients who survive an episode of SBP should be treated with norfloxacin 400 mg daily until the risk of SBP is removed by definitive resolution of the ascites or liver transplantation surgery 2
- Cirrhotic patients with gastrointestinal bleeding or low ascitic protein concentrations should consider primary prevention 3
- Patients with a previous history of spontaneous bacterial peritonitis (secondary prophylaxis) 4
- Patients with low total protein content in ascitic fluid and advanced cirrhosis 4
High-Risk Populations
High-risk populations that may benefit from SBP prophylaxis include: