From the Guidelines
Spontaneous bacterial peritonitis (SBP) prophylaxis is recommended for cirrhotic patients with ascites who have had a previous episode of SBP, or those with low ascitic fluid protein (<1.5 g/dL) combined with either impaired renal function or liver failure, with norfloxacin 400 mg orally once daily as the first-line medication, as supported by the most recent and highest quality study 1. The choice of antibiotic for SBP prophylaxis is crucial, and the most recent evidence suggests that norfloxacin is the preferred option, although alternatives such as ciprofloxacin 500 mg orally once daily or trimethoprim-sulfamethoxazole (TMP-SMX) one double-strength tablet orally daily may be considered in certain cases 1. Some key points to consider when implementing SBP prophylaxis include:
- The risk of SBP and other bacterial infections is high in patients with cirrhosis and acute upper gastrointestinal hemorrhage, and short-term prophylaxis with IV ceftriaxone 1 g daily for 7 days is recommended in these cases 1.
- Patients with a prior episode of SBP are at a very high risk of SBP recurrence, and long-term prophylaxis with norfloxacin or alternative antibiotics is essential to prevent recurrence 1.
- Regular monitoring for adverse effects, antibiotic resistance, and kidney function is essential during long-term prophylaxis, as the emergence of quinolone-resistant organisms has decreased the prophylactic efficacy of norfloxacin 1.
- Addressing the underlying liver disease through alcohol abstinence, hepatitis treatment, or liver transplantation evaluation should accompany prophylaxis to improve overall outcomes. The most recent and highest quality study 1 provides the best evidence for the recommendation of norfloxacin as the first-line medication for SBP prophylaxis, and this should be the preferred choice in clinical practice.
From the Research
SBP Prophylaxis
- The use of antibiotics in the primary prophylaxis for spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is controversial 2.
- Daily oral fluoroquinolone prophylaxis reduces the risk of development of first episode of SBP and mortality in cirrhotic patients with low total protein in the ascitic fluid 2.
- Norfloxacin has been the recommended choice for SBP prevention, but its use has raised concerns about antibiotic resistance 3.
- Rifaximin has been suggested as an alternative to norfloxacin for SBP prophylaxis, and has been shown to be effective in reducing the incidence of SBP in patients with advanced cirrhosis 3.
Primary Prophylaxis
- Primary prophylaxis is indicated in patients with low-protein ascites (ascitic fluid total protein < 1g/dL) and advanced liver disease 4.
- Norfloxacin 400 mg daily is recommended for primary prophylaxis in patients with low-protein ascites and advanced liver disease 4.
- Rifaximin 550 mg twice daily has been shown to be similar to norfloxacin in preventing SBP in patients with primary prophylaxis 3.
Secondary Prophylaxis
- Secondary prophylaxis is indicated in patients who have had a previous episode of SBP 4.
- Norfloxacin 400 mg daily is recommended for secondary prophylaxis in patients who have had a previous episode of SBP 4.
- Rifaximin 550 mg twice daily has been shown to be more effective than norfloxacin in reducing the incidence of SBP in patients with secondary prophylaxis 3.
High-Risk Populations
- Prophylaxis of SBP is indicated in three high-risk populations: patients with acute gastrointestinal hemorrhage, patients with low total protein content in ascitic fluid and advanced cirrhosis, and patients with a previous history of SBP (secondary prophylaxis) 5.