What is the empiric coverage for Spontaneous Bacterial Peritonitis (SBP)?

From the Guidelines

For empiric coverage of spontaneous bacterial peritonitis (SBP), I recommend starting with a carbapenem-based empirical therapy, such as meropenem 1g IV every 8 hours, especially in patients with risk factors for multidrug-resistant organisms, as it has been associated with lower rates of mortality and treatment failure compared to third-generation cephalosporin-based regimens 1. In low-risk community-acquired SBP patients, in settings with low prevalence of drug resistance, a third-generation cephalosporin such as cefotaxime 2g IV every 8 hours can be considered as an alternative 1. Key considerations in choosing empiric coverage for SBP include:

• The high prevalence of multidrug-resistant pathogens in nosocomial SBP, which necessitates the use of broad-spectrum antibiotics such as carbapenems 1
• The importance of adjusting treatment based on culture results when available to minimize resistance development
• The need for long-term prophylaxis with norfloxacin 400mg orally daily or trimethoprim-sulfamethoxazole one double-strength tablet daily in patients who have had previous SBP episodes to prevent recurrence Some important points to consider when treating SBP include:
• Early and appropriate antibiotic therapy is crucial as SBP carries high mortality if not promptly treated
• The use of albumin as standard of care is not universally recommended, and its use should be tailored to individual patient needs
• The choice of empiric antibiotic therapy should be guided by local antimicrobial resistance patterns and patient-specific risk factors for multidrug-resistant organisms 1

From the Research

SBP Empiric Coverage

• The effectiveness of empiric antibiotic coverage for spontaneous bacterial peritonitis (SBP) has been evaluated in several studies 2, 3, 4, 5, 6.
• A study from 2013 found that cefotaxime is effective in 81% of cases, while meropenem is effective in cefotaxime-resistant cases 2.
• Another study from 2019 recommended broad-spectrum antibiotics as empiric therapy for suspected SBP in areas with high rates of multidrug-resistant (MDR) bacteria 3.
• A review article from 2015 suggested that third-generation, broad-spectrum cephalosporins remain a good initial choice for SBP treatment, while levofloxacin is an acceptable alternative for patients not receiving long-term fluoroquinolone prophylaxis or for those with a penicillin allergy 4.
• A study from 2012 found that first-line treatment with cephalosporins provides poor antibiotic coverage, with an overall coverage of 57% 5.
• A study from 2002 found that a short course of ceftriaxone (5 days) is useful therapy for SBP, with a resolution rate of 73% on day 5 of treatment 6.

Antibiotic Coverage

• The overall antibiotic coverage for SBP varies depending on the antibiotic used, with cephalosporins providing 57% coverage 5, piperacillin-tazobactam providing 73% coverage 5, and meropenem providing 72% coverage 5.
• The choice of empiric antibiotic coverage should be based on the local epidemiology of SBP and the presence of MDR bacteria 3.

Treatment Outcomes

• The resolution of SBP and treatment outcomes are dependent on the susceptibility of the microbial etiology to the initial antibiotic treatment 5.
• A study from 2013 found that patients who responded to meropenem had higher lactate dehydrogenase (LDH) and polymorphonuclear cell (PMNL) counts at initiation of alternative antibiotic therapy 2.
• A study from 2002 found that hospital mortality was 12% in patients treated with ceftriaxone for SBP 6.