What is the management of spontaneous bacterial peritonitis (SBP) drainage?

From the Guidelines

Drainage of spontaneous bacterial peritonitis (SBP) is not routinely recommended as a therapeutic intervention, and SBP should be treated primarily with antibiotics rather than drainage procedures. The standard treatment involves empiric antibiotic therapy with a third-generation cephalosporin like ceftriaxone 1-2g IV daily for 5-7 days, or alternatives such as ciprofloxacin or amoxicillin-clavulanate in patients with allergies or based on local resistance patterns, as recommended by the most recent guidelines 1. Diagnostic paracentesis is essential to confirm SBP (defined as ascitic fluid with ≥250 neutrophils/mm³), but therapeutic drainage of the ascitic fluid is not necessary for treatment. In patients with tense ascites causing respiratory compromise, therapeutic paracentesis may be performed to relieve symptoms, but this is not specifically for treating the infection. The infection is cleared by antibiotics penetrating the peritoneal fluid, while the body's immune system helps eliminate the bacteria.

Some key points to consider in the management of SBP include:

• The use of third-generation cephalosporins, such as cefotaxime, as the first-line antibiotic treatment, as they cover most causative organisms and achieve high ascitic fluid concentrations during therapy 1.
• The consideration of alternative antibiotics, such as amoxicillin-clavulanic acid or quinolones, in patients with allergies or based on local resistance patterns, as recommended by the guidelines 1.
• The importance of monitoring the response to antibiotic therapy, with a second paracentesis after 48 hours to check the efficacy of treatment, and adjusting the antibiotic regimen as needed 1.
• The administration of albumin (1.5 g/kg on day 1, followed by 1 g/kg on day 3) in patients with renal dysfunction or bilirubin >4 mg/dL to prevent hepatorenal syndrome and improve survival, as recommended by the guidelines 1.

Overall, the management of SBP should be guided by the most recent and highest-quality evidence, with a focus on empiric antibiotic therapy and supportive care, rather than drainage procedures.

From the Research

Drainage of Spontaneous Bacterial Peritonitis (SBP)

• The key to successful treatment of SBP is a knowledge of appropriate antibiotic regimens and an understanding of the setting in which infection develops, particularly those individuals at high risk for infection 2.
• Treatment of SBP involves the use of non-nephrotoxic broad-spectrum antibiotics expected to cover the typical bacterial flora associated with SBP, with cefotaxime being a commonly used antibiotic 2, 3.
• The simultaneous administration of intravenous albumin and antibiotics for SBP has been shown to result in the decreased development of azotemia and hospitalization-related mortality 2.
• Selective intestinal decontamination (SID) with the oral fluoroquinolone norfloxacin is a form of prophylaxis that can be used to prevent the development and recurrence of SBP, particularly in individuals with low-protein ascites or those awaiting liver transplantation 2, 4.

Antibiotic Regimens

• Cefotaxime is considered one of the first-choice antibiotics in the therapy of SBP, with a dosage of 2 g every 8 hours for a total of 5 days being a common regimen 2.
• Other antibiotic regimens, such as ceftriaxone and ciprofloxacin, have also been shown to be effective in the treatment of SBP, with similar resolution rates and 1-month mortality compared to cefotaxime 5.
• The choice of antibiotic regimen may depend on the specific patient population and the presence of antibiotic resistance, with alternative antibiotics such as meropenem or piperacillin plus tazobactam being considered for patients with nosocomial SBP or those who fail to improve on traditional antibiotic regimens 6, 4.

Risk Factors and Prevention

• Risk factors for developing SBP include advanced age, refractory ascites, variceal bleeding, renal failure, low albumin levels, and a previous diagnosis of SBP 4.
• Long-term antibiotic prophylaxis with norfloxacin can be used to prevent the development and recurrence of SBP in high-risk patients, particularly those with advanced liver disease and ascites 2, 4.
• Withholding acid suppressive medication and discontinuing beta-adrenergic antagonist therapy in patients with end-stage liver disease and resistant ascites may also help to prevent the development of SBP 6.